The Washington Post by BeCreative

NOVEMBER 2008

DIABETES A ROADMAP FOR CHANGE

DIABETES

CONTENTS 2 Changing Diabetes Takes Courage and Leadership 3 An appeal to the President 4 Goal Oriented By 2015, 45 percent of Americans at risk will know their blood glucose level. 5 Assessing the state of diabetes The Triple Barometer will deliver a clear picture of diabetes in America. 6 Coordinating our efforts A National Diabetes Coordinator is needed to deal with efforts to fight diabetes.

Changing Diabetes Takes Courage and Leadership Extraordinary times call for extraordinary leadership and action. America must include steps to change the way diabetes is viewed and treated. Novo Nordisk is proud to be in the forefront of a movement to bring fresh ideas and approaches to preventing and treating diabetes. We dare to dream of an America that changes diabetes from its current state – an escalating epidemic spiraling out of control, with poor outcomes for patients and society – to a

7 Catalyzing a change for families The Catalyst for Better Diabetes Care Act. 8 Diabetes Crisis: the facts and figures 10 Care in the community: help for everyone Empowering minority communities most at risk of diabetes. 10 On the path to diabetes Pre-diabetes raises the risk of diabetes dramatically. 11 Medicare diabetes screening: an underused health benefit Diabetes screening is free for Medicare recipients - not enough are using it.

“One of the major drivers of health care utilization and costs is diabetes, and any plans to change health care in America must include steps to change the way diabetes is viewed and treated.”

12 DAWN Youth How young people are fighting back against diabetes. 13 Divas defeating diabetes No one is keeping quiet about diabetes any longer, thanks to Divabetic! 14 Sense and Scoring How CBO scoring can be changed to deliver better results. 15 Diabetes: a global problem How diabetes affects the rest of the world.

DIABETES: A ROADMAP FOR CHANGE A TITLE FROM MEDIAPLANET Project Manager: Eric Alexander eric.alexander@mediaplanet.com Production: Be Creative Media Group www.becreative.ie Managing Editor BeCreative: Kevin Flanagan kevin@becreative.ie Editor: David Jørgensen david@becreative.ie Design/Prepress: HCL Design Studio +44 283 751 6001 Print: The Washington Post Mediaplanet is the leading worldwide publisher in providing high quality and in-depth analysis on topical industry and market issues, in print, online and broadcast. For more information about supplements in the daily press, please contact Kayvan Salmanpour, 001 646 922 14 00 kayvan.salmanpour@mediaplanet.com www.mediaplanet.com

or the newly-elected Obama Administration, and members of the 111th Congress that will convene on January 6, 2009, the stakes are the highest they have been in generations. Americans will be watching closely as their elected leaders tackle the enormous challenge of setting the

country on the path to an economic recovery. And while Americans are rightly very concerned about their homes, their jobs, and their retirements, they have not lost sight of the value and importance of health care. One of the major drivers of health care utilization and costs is diabetes, and any plans to change health care in

desired state in which much diabetes is prevented, and those who have the disease are appropriately treated to live long and healthier lives. For us, the desired state also includes finding a cure for type 1 diabetes and significantly curbing the costs of treatment and care. As a company with more than 85 years in diabetes, innovative thinking in taking on this disease comes naturally to the people of Novo Nordisk and reflects our passion for helping those with or at risk for diabetes. That’s why we created the National Changing Diabetes® Program in 2005, in partner-

ship with leading organizations in the patient and health care provider communities. Together, we have put forward a bold goal of transforming the current American system of health care and moving it toward one that fully supports all aspects of diabetes cure, prevention, treatment and care. Taking on the challenge of changing diabetes is something that aligns with our company’s philosophy of management. We hold ourselves accountable to a Triple Bottom Line, which means we measure success not only economically, but also in terms of our contributions to society and the patients we serve, and to being good stewards of the environment. For these reasons, we are committed to changing diabetes for the benefit of people who have the disease, those at risk, those affected by it, and society at large. Diabetes is a serious disease. We hope you will read the articles in this special supplement and learn more about many innovative ideas and actions for taking on the challenge of diabetes. We invite you to join us in our quest to change diabetes. Most important, we urge you to have the courage to commit yourselves to changing diabetes as you tackle health care reform in the context of the tough economic challenges facing our country. You’ll have our support, and that of the 24 million Americans with diabetes, and their family members, loved ones, and health care providers. Sincerely, Jerzy Gruhn

DIABETES

An appeal to the President

Dear President-Elect Obama: Y It is time for diabetes to be a national priority. ou campaigned on a theme of hope and change. One area that desperately needs hope – and change – is diabetes. Of the leading causes of death by disease, diabetes is the only one where the death rate continues to increase.

How serious is diabetes? It is often called the “silent killer.” Perhaps it would be more appropriate to call it the “silent destroyer” because, as the leading cause of blindness, amputations, kidney disease and a major contributor to heart attacks and strokes, diabetes very often destroys the quality of life before it kills.

How prevalent is diabetes? Since 1990, fewer than 20 years ago, the number of Americans with chronic, debilitating and life-threatening diabetes has more than doubled to nearly 24 million. Even more worrisome is that diabetes is forecast to more than double again to 50 million by 2025 if the federal and state governments, healthcare systems, public health professionals and the diabetes community cannot come together to develop the means to slow and reverse the onset of diabetes among Americans. Of the children entering first grade during the first year of your presidency, a staggering one in three will go on to develop diabetes. And because diabetes affects ethnic minorities more than whites, if that child is female and Hispanic, she will have a 50:50 chance of developing the disease in her lifetime. In the 75 days since you accepted the Democratic nomination more than 200,000 Americans have developed diabetes, a number greater than twice that of the massive crowd who gathered at Invesco Field, Denver to hear your historic acceptance speech. During this same period, nearly

50,000 Americans have died from diabetes-related complications.

How expensive is diabetes? In 2002 diabetes cost America $132 billion. By 2007 diabetes was costing America $174 billion. By 2025 diabetes is expected to cost our country $351 billion – in 2002 dollars! Today, a person with diabetes costs more than $13,000 per year to treat, compared to $2,500 for someone without the disease. The federal government spends nearly $80 billion a year to treat people with diabetes. Eighteen out of 21 federal agencies have some level of spending that impacts diabetes, but they lack coordination and leadership of those efforts. In addition, nearly all of that money is spent on treatment with little going to prevention. This lack of alignment is undermining the fight against diabetes.

Changing Diabetes – a Solution for the Future While these figures should cause alarm, they should not cause too much despair. We know that if diagnosed and given the right treatment, people with diabetes can protect their health, avoid costly complications, and reduce significantly the tax dollars spent on treatment. We can do this. We know what needs to be done, and it has been proven over and over again. What we need is leadership President-Elect Obama, this serious and debilitating disease calls out for your attention. The crisis of diabetes presents an opportunity to fulfill your promise of hope and to fulfill your commitment to the American people for real change. Changing diabetes changes lives.

As a means of starting a discussion about how best to address this growing problem of diabetes we offer the following cost-effective suggestions for your serious consideration and our pledge to work with you in a publicprivate initiative designed to help the federal government find its voice as a leader in the prevention and improved treatment of diabetes. 1. Launch a national diabetes prevention initiative for Americans in the Medicare program that would help those at risk for diabetes get screened.

2. Champion an effort to achieve the National Diabetes Goal, which is that by 2015, 45% of Americans at risk for type 2 diabetes know their blood glucose level and know what actions to take. 3. Support passage of key bills in Congress that would, among other things, increase access to diabetes education and care by increasing the number of qualified providers, enhance diabetes data collection and dissemination, provide desperately needed support for diabetes initiatives in minority communities that are disproportionately affected by diabetes, and enhance nutrition education coverage for those in Medicare with pre-diabetes. Our country has risen to health challenges before, and the result has been a decline in the death rate in many major diseases. But the impact of diabetes remains staggering, even though we already have the tools and know-how to fight it. With your leadership, we can finally begin to reverse the unhealthy, costly – indeed frightening – diabetes trends currently facing our nation.

Jerzy Gruhn President Novo Nordisk Inc.

R. Stewart Perry Chair of the Board American Diabetes Association

Peter H. Kehoe President American Optometric Association

Amparo Gonzalez President American Association of Diabetes Educators

Fighting diabetes is one issue that can unite Democrats and Republicans... We know that 24 million Americans and their families are counting on this new Administration and new Congress to give diabetes the national focus it deserves, and we’re ready to lead the charge. Rep. Diana DeGette (D-CO) and Rep. Mike Castle (R-DE), Co-Chairs, Congressional Diabetes Caucus

DIABETES

Goal Oriented The NCDP National Goal will make a huge difference on how diabetes will affect America.

he National Diabetes Goal is about making a difference. By answering just one question, the chances of reducing the effects of this major public health issue can perhaps be greater: What kind of progress against diabetes could we make if we unite to achieve one ambitious goal? The answer to that question is simple: By 2015, 45 percent of Americans who are at risk for type 2 diabetes will know their blood glucose level and what actions to take. This achievable goal has the potential to transform the way we deal with diabetes in the United States. A recent survey commissioned by the National Changing Diabetes® Program (NCDP) found that 94 percent of Americans think that diabetes is a serious health issue, and that half of

R. Stewart Perry, Chair of the Board, American Diabetes Association those feel affected on a personal level by it. However, nine Americans die every 20 minutes as a result of diabetes. So while people are aware that diabetes is serious, they are still not getting tested, and diabetes continues to

affect more and more Americans every day. By getting 45 percent of people to have their blood glucose levels tested, preventative action can be taken to ensure that they do not develop type 2 diabetes. Testing at a clinic or physi-

cian’s office will also give people a forum to discuss diabetes, and get advice about its causes. Currently, the NCDP estimates that some 17 percent of Americans are aware of their blood glucose level. Increasing this to 45 percent will have a profound impact on the way we deal with the condition. A simple test at a physician’s office or medical center will empower people to make the necessary changes to their lifestyles to reduce either the impact of diabetes, or to avoid developing it as much as possible. The CDC estimates that one quarter of the nearly 24 million Americans with diabetes do not know they have the disease. Testing will also help to identify these people, and provide a treatment plan – crucial to help to prevent complications such as stroke, heart disease, amputations and blindness. The National Diabetes Goal is supported by some of America’s foremost health and business associations, all united to take action on a public health issue that will have a huge impact on America. With the real possibility of diabetes becoming an overwhelming burden on our health

system, it will also have an increasing impact on the economy, as more capable workers are removed from the workforce. “As a public demonstration of collective will for change and action, leaders from many sectors of society have come together to support the National Diabetes Goal,” says R. Stewart Perry, chairman of the American Diabetes Association. Organizations that are supporting the National Diabetes Goal include the American College of Physicians, the Campaign to End Obesity, the Food Marketing Institute and the National Association of School Nurses (NASN). “Diabetes is taking a heavy toll on students, their families, school personnel, the economy and our nation. NASN supports the National Diabetes Goal,” says Amy Garcia RN, MSN, executive director of NASN. The National Diabetes Goal is simple and achievable. This goal will empower more American people to take control of their own futures. • For more information, visit www.NationalDiabetesGoal.com

By 2015, 45% of Americans who are at risk for type 2 diabetes will know their blood glucose level and what actions to take. These leading advocacy, business and educational organizations are National Diabetes Goal Champions.

NationalDiabetesGoal.com

DIABETES

News Flash The rate of new cases of diagnosed diabetes rose by more than 90 percent among adults over the last ten years, according to a recent study by the Centers for Disease Control and Prevention (CDC). “This dramatic increase in the number of people with diabetes highlights the increasing burden of diabetes across the country,” says lead author Karen Kirtland, Ph.D., with CDC’s Division of Diabetes Translation. Governor Mike Huckabee speaks at the roll-out of the Triple Barometer

Assessing the state of diabetes Getting a clear picture of the nation’s understanding of diabetes.

eople are worried about diabetes.A new poll finds that 94 percent of Americans believe diabetes is as serious, or even more serious than many other major conditions, such as heart disease and cancer. Yet, the poll also shows widespread misconceptions about the disease and who is at risk. Getting a clear picture of the nation’s understanding of diabetes was the aim of a recent Gallup® survey entitled Diabetes in America: Public Knowledge, Perceptions and Behaviors. Carried out on behalf of the National Changing Diabetes® Program, the survey forms part of the National Diabetes Triple Barometer series of studies. The project aims to present a sharp assessment of how diabetes affects the United States from three perspectives: societal, economical, and clinical.

By looking at the impact of diabetes from these three key perspectives, the survey is designed to provide policymakers the information they need to develop strategies that can make a real change in the lives of millions of Americans. Speaking at the launch of the Triple Barometer, former Governor of Arkansas, Mike Huckabee described his own personal experiences with diabetes and said the fight to prevent the spread of diabetes needs to be managed through coordinated efforts and projects such as the Barometer. “When I hear people talk about the health care crisis, I want to correct them and say, ‘No, it’s a health crisis.’ And the greatest challenge we face is not access into a system, because that’s the problem, we don’t have a system, we have a maze. The biggest problem is that we spend most of our

resources on trying to intervene at the level of a disease when it’s in catastrophic condition, when we need to be putting the focus on preventing the disease before it ever hits them,” said Gov. Huckabee in his keynote address. The Societal Barometer showed high recognition of the importance of diabetes, but it also suggested that this concern is not translating into action. One reason for this appears to be a lack of understanding of what can cause diabetes, who is at highest risk, and what individuals can do to reduce their chances of developing the disease. Two stark statistics from this Barometer show why diabetes will continue to be an overwhelming health problem for the United States in the next few years. Only 27 percent of those surveyed knew that moderate daily exercise could help prevent or delay the onset of diabetes.

In addition to this, a startlingly low proportion of people – just 11 percent – knew that ethnicity could be a considerable factor in determining who may end up with diabetes. Studies show that African- Americans, Latino/Hispanic Americans, Native Americans, Asian Americans and Pacific Islanders, run a higher risk of developing diabetes. Even those who have a higher awareness of diabetes, and have actually had their blood-glucose levels tested, are still generally unsure of why blood-glucose levels are so important in keeping diabetes under control. Almost three-quarters of those surveyed did not recall which particular test they had had, and 80 percent did not know why the test was being done. The Clinical Barometer seeks to determine the outcomes of existing diabetes treatment in the United States. Aiming to deliver a view of clinical care delivery, this second part of the Triple Barometer will help to formulate ongoing policy in response to diabetes, and how it is treated. It will also help to determine how patients are treated for the effects of diabetes – complications such as loss of eyesight, heart disease, kidney problems, leg amputations and early death. If action is not taken now, it is projected that some 50 million Americans

will be living with type 2 diabetes and its complications by 2025. Experts warn that the impact on the heath care system will strain resources in ways not seen before. The burden will radically change the way that government needs to respond to diabetes and dictate how other health care organizations and insurers will need to adapt. In short, this problem will have huge costs, which will be paid in both dollars and human lives. The financial cost is one that everyone will have to shoulder – employer and taxpayer alike. The third part of the series, the Economic Barometer, is exploring how that cost is being met. Looking at the specific costs of diabetes by type – type-1 and type-2, diagnosed and undiagnosed diabetes, pre-diabetes (the condition that could lead to full-blown diabetes), and gestational diabetes – the study will also aim to identify gaps in health care, and how these can be improved. The Triple Barometer is intended to help push diabetes to the top of the health agenda, and will be an important series of studies for anyone involved with providing health care in America. To make a difference, however it is vital that this information be acted upon immediately so we can avert the crisis that is looming on the near horizon.

DIABETES

Coordinating our efforts A National Diabetes Coordinator is needed to lead an effort to reduce the prevalence of the condition.

From 19802003, changes in death rates due to major diseases: • Diabetes – up 40% • Cancer – down 10% • Heart disease – down 45% • Stroke – down 45% Source: Data adapted from the Centers for Disease Control and Prevention, Health, 2006

eath rates from major diseases such as cancer and heart disease have declined in recent years, but one killer-diabetescontinues to rise in both prevalence and mortality. Reversing that trend will require strong leadership to help Americans make the kinds of changes that will pay off in better health, say diabetes experts. The U.S. government spends almost $80 billion a year on diabetes – similar to the annual budget of the Department of Education, according to a recent study commissioned by the National Changing Diabetes® Program (NCDP). The study also found that nearly all federal expenditures go to the care and treatment of diabetes, while less than 1% of that expenditure goes toward prevention of diabetes. Of the 21 federal government agen-

cies, 18 spend money on diabetes programs. But unlike the federal approach to AIDS or cancer, there is no formal strategy for determining how the money should be spent and very little coordination of efforts across those agencies. “No one in the White House or any high level of government comes to work each day charged specifically with thinking about ways to stop and reverse the diabetes epidemic,” says Dr. Alan Moses, Global Chief Medical Officer for Diabetes and Metabolism at Novo Nordisk Inc. and former chief medical officer at the Joslin Diabetes Clinic in Boston, Massachusetts. “The federal activities around the growing diabetes crisis reflect lots of action and little coordination. The piecemeal approach allows for little if any crossagency coordination and leadership.”

A bill introduced by Rep. Jay Inslee (D-WA) in the House (HR 4836) and Sen. Thad Cochran (R-MS) in the Senate (S 2742) calls for the creation of a National Diabetes Coordinator.

Actress, correspondent, and humanitarian Maria Menounos talks with Congressman Eliot Engel of New York on the Capitol Subway about the need for a National Diabetes Coordinator.

Congressman Jay Inslee of Washington State In the mid-1970s, when a National Commission on Diabetes delivered a Long-Range Plan to Combat Diabetes to Congress, only four to five million Americans were living with diagnosed diabetes.Today, the Centers for Disease Control and Prevention estimates that 23.6 million Americans have the disease and a quarter of them don’t know it, so they are not taking steps to prevent complications such as heart disease, blindness or amputation. In addition to the growing number of Americans who already have diabetes, a staggering 54 million more are at high risk of developing it – they have pre-diabetes, a condition in which blood glucose levels are higher than normal. Advocates say the National Diabetes Coordinator Act will ensure that federal dollars and programs are targeted toward prevention, improved care, and eliminating wasteful duplication of efforts. It is “an important step toward aligning the federal programs and resources necessary to improve the quality of life for the more than 20 million Americans with diabetes,’’ says the American Association of Diabetes Educators, which supports the legislation, along with

the American Association of Clinical Endocrinologists and Novo Nordisk. “With every new repor t on the growing diabetes crisis it seems like we are losing the battle against this insidious disease,” says Dr. Moses. “A National Diabetes Coordinator will make sure the federal resources devoted to diabetes prevention and care are used effectively and efficiently to save lives and money. “I am convinced that without ongoing leadership from the highest levels of government that we cannot – and will not – reverse this horrible disease.”

“A National Diabetes Coordinator would keep diabetes at the top of our national agenda, align our resources, and maximize results – it makes good sense.” U.S. Rep. Jay Inslee (D-WA)

DIABETES

Catalyzing a change for families Diabetes is a disease that gets progressively worse.

he longer diabetes goes untreated, the more damage it causes. The good news is that in many cases diabetes can be prevented; in others, prompt treatment can ward off many of its deadly complications. A bill introduced in Congress will increase the number of Medicare recipients screened for diabetes, a benefit that is already part of their coverage, by requiring development of an aggressive outreach program. More screening of older people at risk for diabetes could dramatically lower the number of undiagnosed – and untreated – cases, now estimated at nearly 6 million people. It could also identify some of the estimated 54 million Americans with above-normal blood glucose levels, a

condition known as pre-diabetes. If people know they are in this category, they can take steps to lose weight and increase exercise, which have been proven to delay or prevent diabetes from developing. The value of early screening and of not waiting to diagnose people until they have symptoms of diabetes was underscored recently by American Diabetes Association President and professor at the University of North Carolina School of Medicine John Buse, M.D., Ph.D. who recently told AARP Magazine “If we just wait for people to come in with symptoms, the body’s machinery is so messed up that it’s hard to do a good job with treating the illness.”

The Catalyst for Better Diabetes Care Act will also: • Promote wellness activities and develop best practices for disease management through a private and public sector advisory committee • Create a Diabetes Report Card to track national progress in combating diabetes and its complications. • Assist states in improving statistical data tracking on death certificates to provide a clearer picture of the impact of diabetes. • Charge the Institute of Medicine to assess the level of diabetes education in medical schools, in light of the alarming increase in diabetes prevalence. Diabetes experts say these steps can increase understanding of the scope of

“My family has seen the impact of diabetes up close for more than a decade... Diabetes is an illness that affects millions of people – and yet, many do not know they have it or at risk of getting it.” Congressman Zack Space (D-OH)

diabetes, providing assessments that can help to inform public policy decisions, and will form the foundation for a much-needed change in attitudes toward prevention and care – big reasons why the bill is supported by the American Diabetes Association, the Healthcare Leadership Council, and many other organizations. In fact, a coalition of the bill’s supporters, including the American Academy of Physician Assistants, American Association of Diabetes Educators, American Optometric Association, Novo Nordisk and others say the Act’s provisions will “help us improve the care and treatment of people with diabetes, ultimately preventing the disease and its deadly complications.” “My family has seen the impact of diabetes up close for more than a decade,” says Congressman Zack Space (D-OH). “My son – like millions of Americans – must deal with the constant injections, blood tests,and above all,the fear of how

the disease could affect his body in the future.He has accepted his condition admirably, and our family could not be prouder of him. “Diabetes is an illness that affects millions of people – and yet, many do not know they have it or at risk of getting it. I hope to see that trend diminished and will continue to work tirelessly in Congress toward that goal.”

The Catalyst to Better Diabetes Care Act (HR 3544) was introduced in the House by Rep. Zack Space (D-OH) and in the Senate (S 2479) by Sens. Brown (D-OH) and Cornyn (R-TX).

DIABETES

Diabetes Crisis: No End in Sight Diabetes Today and in 2025 The diabetes burden for the entire US population

Today

2025

Total with diabetes

23.6 million

50 million

Undiagnosed Segment

5.7 million

15 million

Blindness

24,000

70,000

Amputations

82,000

239,000

Kidney Failure

44,400

119,000

Death

224,092

622,000

Annual cost of diabetes

$174 billion

$351 billion

Complications

Every 20 minutes 60 Americans will be diagnosed with diabetesâ&#x20AC;Ś 9 Americans will die 3 Americans will have a limb amputated 2 Americans will have kidney failure 1 American will go blind

â&#x20AC;Śdue to diabetes

BUSINESS DIABETES TRAVEL

No Data

A nationwide epidemic growing >26.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% No <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% No Data No Data <14.0% <14.0% 14.0-17.9% 14.0-17.9% 18.0-21.9% 18.0-21. atDataan unprecedented rate

betes Diabetes Diabetes 2000 1994 1994 betes Diabetes 1994

>26.0% 18.0-21.9% 22.0-25.9% 18.0-21.9% 14.0-17.9% 14.0-17.9% 18.0-21.9% 22.0-25.9% <14.0% 22.0

<14.0% No Data 14.0-17.9% <14.0% No Data

2000

1994

2000

4.5-5.9% 6.0-7.4% 7.5-8.9% No Data <4.5% 4.5-5.9% No Data No Data <4.5%

No Data

<4.5% No Data 4.5-5.9% <4.5% No Data

6.0-7.4% 4.5-5.9% <4.5%

2007

2000

2000 2007

> 9.0% 6.0-7.4% 4.5-5.9% 7.5-8.9% 6.0-7.4% <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% 6.0-7.4% 4.5-5.9%

> 9.0% 7.5-8.9% 6.0-7.4%

7.5-

etes Translation. National Diabetes Surveillance System available at CDC’s Division ofCDC’s Diabetes Translation. National Diabetes Surveillance System av Division CDC’s of Division Diabetes of Diabetes Translation. Translation. National Diabetes National Diabe Surve iabetes/statistics Age-adjusted percentage of US adults who had diagnosed diabetes http://www.cdc.gov/diabetes/statistics http://www.cdc.gov/diabetes/statistics s Division of CDC’s Diabetes Translation. National DiabetesNational Surveillance System availableSurveillan at Division ofhttp://www.cdc.gov/diabetes/statistics Diabetes Translation. Diabetes Surveillance System av CDC’s Division of Diabetes Translation. National Diabetes //www.cdc.gov/diabetes/statistics http://www.cdc.gov/diabetes/statistics http://www.cdc.gov/diabetes/statisticsCDC. Maps of diabetes and obesity in 1994, 2000 and 2007. http://www.cdc.gov/diabetes/statistics/slides/maps_diabetesobesity94.pdf. May 2008.

Per capita medical expenditures are $13,243 for people with diabetes compared to $2,560 for people without diabetes.

Treatment of preventable diabetic complications costs $22.9 billion per year in direct medical costs.

1 in 3 children born in 2000 will develop diabetes. This number rises to 1 in 2 among minorities.

The Diabetes Prevention Program showed that modest weight loss and regular exercise reduced diabetes incidence by 58%, and by 71% in those over 60.

DIABETES

Care in the community: help for everyone Knowledge is power, and for America’s minority communities, knowledge about diabetes can also be empowering.

he risk of developing diabetes is significantly higher for members of ethnic and racial minority communities than for white Americans, according to the U.S. Centers for Disease Control and Prevention. Without early diagnosis and accurate information, diabetes can be improperly treated or not treated at all, leading to disabling or deadly complications such as cardiovascular disease, kidney disease, blindness and amputation. Many of these serious, often completely preventable conditions affect minorities disproportionately:African Americans are more likely than whites to die of diabetic ke-

toacidosis, a condition caused by severely high blood glucose levels.They also suffer higher rates of end-stage kidney disease and lower leg amputation as a result of diabetes-associated damage. Diabetes is not a disease that can be cured by a pill. Doctors, diabetes educators and nutritionists may be part of a diabetes care team, but it is up to the patient to manage the disease every day. Access to good medical care and clear, culturally appropriate information is critically important for minority communities. Right now, such care is not always available. But that could change.

“Action is urgently needed to protect the health of our citizens, young and old, who are affected by this disease. I will fight in this next Congress to make diabetes a national priority.” Jim Clyburn (D-SC), Majority Whip, U.S. House of Representatives

Ensuring that everyone gets access to information and help for diabetes is the goal of the Diabetes Prevention Access and Care Act (DPAC), which will reduce health disparities by specifically focusing on identifying and addressing the needs of minority communities in preventing diabetes and treating those who are already living with the condition. Studies have shown that many members of minority communities are hesitant to work with health professionals who are not familiar with their language and cultural backgrounds.To address this problem, the bill also provides for mentoring and internship programs to increase the number of minority physicians and other health professionals. It requires the National Institutes of Health to focus more research on discovering why diabetes is so prevalent in America’s minority populations, supporting research on genetics, environmental factors and behaviors that contribute to diabetes. By better understanding the interplay between genetic predisposition and the environment, scientists may be

House Deputy Whip John Lewis of Georgia talks with NBA Hall of Famer and diabetes advocate Dominique Wilkins. able to develop therapies to prevent or delay onset of disease. Under the provisions of DPAC, the Centers for Disease Control and Prevention will conduct research and support community programs to educate minority groups about how diabetes can develop, how it can be prevented, and how it can be managed.It calls for expanding the National Diabetes Education Program and establishing partnerships with minority populations to study cultural and so-

cial factors that can influence diabetes management and prevention. “Diabetes has emerged as the greatest public health crisis of the 21st century,and among minority communities the footprint of this disease is even greater,’’ Dr. John Anderson, chair of the American Diabetes Association’s National Advocacy Committee,told PRNewswire.Legislation like DPAC, he said, can “raise the level of awareness about diabetes and the level of care in underserved communities.’’

The Diabetes Prevention Access and Care (DPAC) Act (HR 2210) was introduced to Congress by Reps. DeGette (D-CO) and Castle (R-DE), and in the Senate (S 2983) by Sens. Lautenberg (D-NJ) and Isakson (R-GA).

On the path to diabetes Those with pre-diabetes are likely to develop type 2 diabetes within 10 years, unless they take steps to prevent or delay diabetes.

“If we just wait for people to come in with symptoms, the body's machinery is so messed up that it's hard to do a good job with treating the illness.” John Buse, MD, Ph.D, President, American Diabetes Association and professor at the University of North Carolina School of Medicine

ccording to the American Diabetes Association, nearly 54 million Americans have prediabetes, which sharply raises the risk for developing type 2 diabetes and increases the risk of heart disease by 50 percent. Pre-diabetes is a condition where blood glucose levels are abnormally high-- but not yet high enough to be considered diabetes. Currently, there are proposals in Congress such as The Preventing Diabetes in Medicare Act to help seniors diagnosed with pre-diabetes avoid developing full-blown diabetes by providing access to the best possible nutritional advice about how to handle their condition. Given the enormous difference in medical costs between those who have diabetes and those who do not, we can improve the

quality of life for millions of people – and save money – by preventing diabetes. Combined with screening to find those with undiagnosed pre-diabetes, providing people with pre-diabetes the information and support necessary to manage their condition will make a long-term difference and help reverse the current trajectory of our nation’s diabetes problem. By

helping people with pre-diabetes manage their condition, Medicare will avoid having to pay for the much more expensive treatment of diabetes. “We know that diabetes is hitting people younger and younger all the time. We have to do something to prevent diabetes,” said Sen. Tom Harkin (D-IA), in comments on the Senate floor.

The Preventing Diabetes in Medicare Act (HR 2922) was introduced in the House by Reps. DeGette (D-CO) and Castle (R-DE), and included in Senate bill 1342, the Healthy Lifestyles and Prevention America Act, introduced by Sen. Tom Harkin (D-IA).

DIABETES

The Medicare Diabetes Screening Project The Medicare Diabetes Screening Project is working at the grassroots level to get the message out about the free screening test. For example, in Columbus, Georgia, ministers at 15 churches preached on diabetes screening and distributed more than 5,000 Medicare diabetes screening bulletin inserts to parishioners at Sunday services. Fire stations in 14 Columbus neighborhoods have emergency medical personnel available from 9am to 9pm every day for the public to seek advice on whether they are at risk of the disease and where and how they can get a free Medicare diabetes screening test. They are joined in this effort in Columbus by pharmacists, senior serving agencies, optometrists, the Chamber of Commerce, city agencies, the media, any many other organizations and individuals.

Local and national leaders kick off the Medicare Diabetes Screening Project in Columbus, Georgia.

Medicare diabetes screening: an underused health benefit Diabetes screening is free for Medicare recipients, but too few take advantage of it.

here are many shocking statistics about diabetes but perhaps one of the most surprising is that in 2006 (the most recent year for which data currently exists) fewer than 10 percent of Medicare beneficiaries took advantage of free Medicare diabetes screening by taking a fasting glucose test. It is alarming because estimates suggest that of the 35 million older adults in Medicare, almost half have undiagnosed diabetes or pre-diabetes. As many as two to three million adults aged 65 and older with diabetes and 14 million with pre-diabetes are undiagnosed and so not receiving medical treatment. At the same time, those who are undiagnosed are not receiving help in making moderate changes to their lifestyle through increased exercise and eating more healthily, which can help reduce blood glucose levels naturally and, in the case of pre-diabetes,

help delay or prevent the condition from developing into diabetes. The Medicare Diabetes Screening Project is a national coalition of more than 20 organizations, co-chaired by the American Diabetes Association, Healthcare Leadership Council and Novo Nordisk. Its aim is to improve public awareness of the free test for older adults who have a family history of diabetes, are overweight or have other risk factors for diabetes. Authorized by Congress to begin in 2005, the low uptake of the test is worrying because it is designed to help prevent diabetes as well as diagnose it. People are risking their health unnecessarily through either not taking the test or simply not realizing it is available. “Congress took the unprecedented step of letting Medicare offer this test

for free because of the inarguable results of the federally sponsored Diabetes Prevention Program (DPP),” says Michael Mawby, chief government affairs officer for Novo Nordisk. “The DPP proved that people over 60 with pre-diabetes who lose just 4-7 percent of their body weight and increase their physical activity by walking for 30 minutes just five days of the week, can reduce their risk of developing diabetes by as much as 70 percent. Such small steps can offer big rewards, but only if people know they are at risk so we’ve got to spread the word about the test. If people don’t know they have diabetes or pre-diabetes, they have less incentive to take action.” The prevention message is all the more important when one considers that more than a quarter of the

Almost half of older adults in Medicare have undiagnosed diabetes or pre-diabetes.

Medicare budget is spent on treating people with diabetes. Reaching out to those with pre-diabetes and helping them to prevent the onset of the disease makes sense for the individual as well as the Medicare budget. “This needs to be a high priority for CMS (Centers for Medicare and Medicaid Services) and for the CDC (Centers for Disease Control and Prevention) which has made primary prevention a priority,” says Mawby. “There is a tremendous opportunity for public health officials to demonstrate leadership by encouraging and enabling communities to help older adults get screened for diabetes. If CMS and CDC were to come together and agree to make promotion of Medicare diabetes screening benefits a mutual priority, it would be an outstanding example of an effective federal partnership, and one that the diabetes community would welcome and support.”

The national partners working on the Medicare Diabetes Screening Project include: • Administration on Aging • America’s Health Insurance Plans • American Academy of Physician Assistants • American Association of Diabetes Educators • American Clinical Laboratory Association • American College of Physicians • American Diabetes Association (Co-Chair) • American Dietetic Association • American Medical Association • American Optometric Association • Avalere Health • Center for Health Transformation • DMAA: The Care Continuum • Healthcare Leadership Council (Co-Chair) • Healthways • National Association of Area Agencies on Aging • National Association of Manufacturers • National Association of State Units on Aging • National Black Nurses Association • National Council on Aging • Novo Nordisk (Co-Chair) • Vision Service Plan • XL Health

DIABETES

DAWN Youth Diabetes is tough for anyone, but for children and young adults, it comes with extra challenges. Monitoring and managing the disease can affect everything from family meals, to after-school activities to whether it’s OK to go out for pizza with the gang on a Friday night.

ach phase of growth, with its physical and emotional changes, brings adjustments that children without diabetes may never have to consider. Young people with diabetes need the support of their healthcare providers, family, friends and school to negotiate the choppy waters of adolescence with a sense of confidence and pride. That is the focus of DAWN Youth. It is a global program that aims to help empower young people with diabetes to become their own advocates. DAWN Youth grew out of the Diabetes Attitudes, Wishes and Needs (DAWN) program launched in 2001 by Novo Nordisk and the International Diabetes Federation. That program began with a large study, involving 3,800 healthcare professionals and more than 5,400 people in 13 countries.The main finding: If diabetes care focuses only on the physical, the needs of the patient are not being met, and treatment suffers. The DAWN Program goal is to identify and overcome the psychological and social barriers that can keep people with diabetes from taking the best care of themselves. DAWN Youth does the same, taking into account the special, often unmet needs of young people. It acknowledges that for children and teens with diabetes, needs are different. And it gives young people a platform to share their experiences as it relates to a variety of topics including friends and family relationships, coping with diabetes and the self-management it requires in dealing with diabetes at school. A DAWN Youth WebTalk Survey was conducted last year to gain more insight into the viewpoints of parents of children with diabetes under 18 years of age, young adults with diabetes

Dana Lewis, DAWN Youth Ambassador

DAWN Youth Ambassadors engage with young people with diabetes between the ages of 18 to 25 and healthcare providers. The U.S. results from this survey will be released at the Young Voices: Life with Diabetes forum, taking place in New York City on World Diabetes Day, Nov. 14, 2008.

This event is being hosted by Novo Nordisk, the Juvenile Diabetes Research Foundation (JDRF), Discovery Health, and Discovery Education. “This project builds on the project established last year between Novo

Nordisk and Discovery Health in which the two organizations collaborated on an award winning documentary profiling the growing incidence of diabetes,” said Dr. John Whyte, VP, Continuing Medical Education at Discovery Health. The Young Voices: Life with Diabetes youth forum, moderated by ESPN anchor Brian Kenny, will bring together teens and young adults living with type-1 diabetes to share experiences dealing with life transitions while managing their diabetes. Prior to the event, young people with diabetes were asked to record a one minute video to the incoming president. This video provides an opportunity to voice their wishes, attitudes and needs and to ask the government to acknowledge their issues and help improve diabetes care. Videos will be featured during the event. JDRF is also working on a number of projects to encourage on-going communication between young people and those who are providing solutions to diabetes care. “The on-line social networking program will allow young people with diabetes to connect with each other, share advice and support each other,’’ says Deno Syrios, National Director at JDRF.“The site will carry accurate, relevant information to help young people at a variety of life stages and circumstances.” For Novo Nordisk, the DAWN Youth program is one way the company is changing the future of diabetes. “We strongly believe that all young people with diabetes should have the right to receive the best possible care and the chance to lead full and healthy lives,’’ says Dorothy Collins , who manages the DAWN Youth program at Novo Nordisk. “DAWN Youth provides everyone with an opportunity to help make that happen.’’

Dana’s story Dana Lewis, 20, of Huntsville, Ala., was diagnosed with type 1 diabetes six years ago. It was a shock, she admits – but she didn’t let it sideline her. Now a student of public relations and political science at the University of Alabama, she has been a DAWN Youth Ambassador for two years, spreading the message to other young people that diabetes is a manageable condition that need not limit their abilities to reach for the highest goals. Youth Ambassadors like Dana around the world are providing inspiration not only to young people with diabetes, but also to healthcare professionals and policymakers in government. As a teenager with diabetes, Dana says she’s very aware of the feelings and emotions that diabetes can provoke – and, of course, the practicalities of dealing with the condition. “The need for psychosocial support is very important,” says Dana. “When I was diagnosed I went through many emotions. I cried, but I knew that I had to deal with this. It took me some time before I came to terms with it, though.” She’s the first to note that dealing with diabetes is not just about taking insulin, having a balanced diet, and exercising regularly. “There is a lot of motivation required,” she says. “So many other factors can affect diabetes, such as stress and emotions – at that age if you have a fight with a friend, that can be a really traumatic experience, but for those with diabetes, it can also be a factor that affects your blood sugar level.” Dana is considering a career in public health, but her advocacy began long ago. At the University, she helped lead an effort to make sure campus restaurants post nutritional information about all food served, so people with diabetes can make informed decisions. Though she says that as the semester winds down, she has little time now for anything but hitting the books, as a DAWN Youth Ambassador, she has forged a path for others to follow.

6 out of 10 children with diabetes do not manage their diabetes successfully in school 9 out of 10 cannot rely on a school nurse to assist them with their diabetes during school 3 out of 4 believe diabetes has an impact on their performance at school Source: DAWN Youth Survey

DIABETES

Divas defeating diabetes Grab your boa and your sparkly heels. If you have diabetes, there is no need to keep quiet about it. In fact, according to Max Szadek, you should be a diva.

Max Szadek engages divas for an evening of makeovers.

want people to feel so good about themselves,” says Max Szadek. To help make that happen, he founded Divabetic – a nonprofit organization aimed at making women with diabetes feel self-confident, informed, strong and beautiful inside and out. The group’s signature program, Novo Nordisk Presents: Divabetic – Makeover Your Diabetes, held in venues throughout the U.S., has brought together thousands of women for an afternoon or evening of fun and free services, from hair styling to manicures, makeup sessions and photo shoots. While they’re having a good time getting glamorous, the women also have the chance to meet with Certified Diabetes Educators, nutrition counselors and other experts to get tips on living – and living very well – with diabetes. Through a partnership with Novo Nordisk, at each Divabetic- Makeover Your Diabetes event, educational stations are set up that focus on topics of interest such as Grab Green & Go, which offers tips on how to make healthier food choices,Twist and Shout, which shows how to boost daily exercise without having to spend hours at a gym, and Glam More Fear Less, focusing on improving self-image and, “unleashing the diva within,’’ Szadek says.

“A lot of people are just overwhelmed with the amount of information that is out there,’’ Szadek says. “More and more people are being affected by diabetes, and people are concerned about how they can deal with it. We decided to break down the education elements into smaller increments, and have it be progressive. At the events, people learn a little, get up and move to another area, learn some more, and move on.” This kind of information is important, because women, as the main caregivers in most families, tend to take care of everyone else before themselves, he says. But at Divabetic – Makeover Your Diabetes events, it’s all about them. Often, because they have not taken such good care of themselves,“people have issues with their size,” Szadek says. “I want everyone who walks in, no matter where they are in their lives, to know that we will work with them, lift them up a little bit, and get them moving in the right direction.” “Going to a Divabetic – Makeover Your Diabetes event changed my attitude about this disease and helped me not be so ashamed of it,” says Carole O’Donnell, 49, who participated in the program.“For the first time, I am talking about my diabetes. I don't hide my

The Fabulous Mother Love and fellow divas smile for the camera.

Guests have an opportunity to connect with Certified Diabetes Educators to talk about diabetes. condition anymore. I have my meters everywhere instead of hiding them,” she says of her experience at Denial’s Not My Style, an educational station that focuses on overcoming anxiety about blood sugar levels, cholesterol and body mass index. Szadek, a long-time friend and personal assistant to multiple-Grammywinning R&B artist Luther Vandross, conceived the idea for Divabetic after Vandross, who had diabetes, suffered a stroke in 2003.Vandross died in 2005, following a second stroke. Between those events, on a night in 2004, “I was watching that great diva Patti LaBelle perform on stage,’’ Szadek says. “At one point, she stopped the

show, and declared that, ‘diabetes doesn’t control me, I control my diabetes!’ It was at that moment that I realized that Patti wasn’t just a diva or a diabetic – she was a divabetic!’’ “Novo Nordisk became involved with Divabetic in response to growing evidence regarding the challenges the diabetes community faces in finding the motivation to manage this condition” says Dr. Soraly Servera, Medical Scientific Director at Novo Nordisk. “It was important to us, as a partner to people

living with diabetes, to provide diabetes education in a unique way and in an empowering and supportive community environment that fosters encouragement to improve how they are living with the disease.” It is a message that packs power, say those who have attended. “When I was diagnosed with type 2 diabetes, I knew I had to lose weight and get in better physical shape but I couldn’t stick to a diet and exercise plan,” says Vickie Williams, who participated in Sweet Inspirations, an area focused on goal-setting and affirmations. “An educator worked with me to commit to realistic milestones I could celebrate as I achieved. Today, I walk on the treadmill every other day, 10 minutes at a time, and then bicycle 10 minutes.” O’Donnell says her new attitude and knowledge will cross into the next generation. “I have conversations with my kids, especially my oldest daughter who is built like me,’’ O’Donnell says. “Using what I learned at Grab Green and Go, I know I am teaching her good eating habits.”

“For the first time, I am talking about my diabetes. I don't hide my condition anymore.” Carole O’Donnell

DIABETES

Sense and Scoring Congressional Budget Office (CBO) scoring is a process of determining the cost of legislation, whether pending or already enacted, and plays a major role in determining the fate of a bill.

hen the legislation pertains to medical care, improvements in scoring can have profound benefits and ensure that the true savings from disease prevention are factored into a particular bill’s cost. As it stands, the estimation process of the CBO and the Office of Management and Budget (OMB) tends to have a limited view in its forecasts, operating with a smaller timewindow and not taking into account how an acute or chronic disease state actually works. The National Changing Diabetes® Program (NCDP) is working to ad-

vance the scoring process, so that the long-term benefits of legislation can be more accurately assessed. The objectives of the soon-to-be-published research and recommendations are to: • Evaluate current scoring methods, particularly with reference to activities covering diabetes and other chronic health conditions • Develop new approaches to scoring for health-related legislation • Create a consensus among NCDP member associations and other impacted stakeholders

Congresswoman Donna Christensen of the Virgin Islands addressing participants at a Capitol Hill briefing on changing CBO scoring. • Collaborate with those who work in scoring the cost of legislation in order to identify where changes can be made, and how new techniques can improve delivery Raising awareness of the existing issues regarding CBO scoring is an important factor in helping to determine how effective new legislation can be.

Having an accurate system to measure the deliverables of a project is regarded as good management. In the same way, having more accurate and comprehensive ways of determining

the outcome of legislation will help to create better, more targeted bills - ensuring that health prevention activities are considered as investments that produce returns for the taxpayer.

The NCDP is working to advance the scoring process, so that the long-term benefits of legislation can be more accurately assessed.

9[[aAa2Ka[uuuPaDK[@02Ha20B-#&-0$-$Kya2-$02a0$-9-a2K[@0$Kao-2-)0 K)0a[-02HK[@u0#y2;aRRD0$aK[@0K20K)0z;K2-0a[a2H-&u 5K[a[yKaR0K[A-)2V-[20a[$02H-0Va)20a$Aa[y-$0&-)-a&yH0a&-0pa&20 a902H-0-z;a2Ka[!0o;20[a20[-a&RD0-[a;@H02a0&-ayH0a;&0@aaRu0 Ra0ya[9&a[202HK)0-pK$-VKy!0K20BKRR0aR)a02aQ-0)aV-2HK[@02Ha2 $&KA-)0CaAa0Ca&$K)Q•0pa))Ka[u Z-0p;&);-0a;&0@aaR0BK2H0a0pa))Ka[02Ha20ya[0a[RD0yaV-09&aV0a0 yaVpa[D0BK2H0a[02;JD-a&0HK)2a&D0a90K[[aAa2Ka[0K[0$Kao-2-)0ya&-u0 Z-0$-$Kya2-0)K@[K9Kya[20&-)a;&y-)02a0$Kao-2-)0&-)-a&yH0a[$0BKRR0 ya[2K[;-02a0$a0)a0;[2KR0a0y;&-0K)09a;[$u0Z-0-[$aB0a$Aa[y-$ &-)-a&yH09ayKRK2K-)!0a[$0a&-0a202H-09a&-9&a[20a900)2-VJy-RR0&-)-a&yH0 K[0$Kao-2-)u0RH-0&-);R2){0RH-00o&aa$-)20$Kao-2-)0p&a$;y20pa&29aRKa0 aAaRaoR-09a&0pa2K-[2)u0M&a@&aV)02Ha20VaQ-0a0&-aR0$K99-&-[y-0K[ pa2K-[2)#0RKA-)u0#[$0a0AK)Ka[09a&0,Ha[@K[@0.Kao-2-)'0a[$0 $-9-a2K[@0K20K[0a;&0RK9-2KV-u

K)0a0&-@K)2-&-$02&a$-Va&Q0a90 CaAa0Ca&$K)Q0#/P0"09JJ2

DIABETES

Diabetes: a global problem By 2025, 350 million people around the world could have diabetes.

merica is facing an explosion in the numbers of people who will have to live with the daily realities of diabetes and the same situation is being repeated throughout the world. By 2025 – the year when there could potentially be 50 million Americans with diabetes – the World Diabetes Foundation (WDF) predicts that 80 percent of all new cases of diabetes will appear in developing countries.That means that, without intervention, as many as 350 million people around the world could have diabetes. Studies carried out recently in Zambia, Mali and Mozambique highlight a stark reality: a person requiring insulin for survival in Zambia will live an average of 11 years; a person in Mali can expect to live for 30 months; in Mozambique a person requiring insulin will be dead within 12 months. America has to confront the economic realities of diabetes as it im-

pacts the economy and health systems, but for those in the developing world, the situation will literally mean life or death. In many countries, poor people with diabetes will be unable to pay for insulin or other medication to deal with the effects. The International Diabetes Federation estimates that as many as 80 percent of people in poorer countries now pay for their own drug treatments and other medical supplies. For low-income people in India, diabetes management can eat up a quarter of the family’s budget. In Latin America, the proportion of the budget spent on diabetes care can be as much as 60 percent. Last year, the international fight against diabetes cost between $215375 billion, and that figure is expected to rise exponentially over the next few years if nothing is done to stem the growing prevalence of the disease. Because the quality of medical care, and access to it, are often linked

with income levels, public health experts fear the human toll of diabetes could be far higher in developing countries than in more affluent regions of the world. Early diagnosis and treatment can prevent many of the devastating and costly complications of diabetes, such as amputation and kidney disease, but in developing countries access to screening tests may be difficult to provide, leading to a growing proportion of people who go undiagnosed and untreated. Even when it is properly diagnosed and medication is available, diabetes is a disease that requires self-management, making education a vital component of good medical care. In countries already struggling with poverty and a host of other medical issues, there may not be resources to provide the support and information needed, especially in rural areas. The World Health Organization predicts that diabetes deaths will in-

crease by more than 50% in the next decade without prompt action. It has been over a year since the United Nations passed its first resolution recognizing that diabetes poses as serious a threat to world health as infectious diseases, such as HIV/AIDS, tubercu-

losis and malaria. Another World Diabetes Day is coming up on November 14, with a focus on children.This is a chance for Americans to unite with partners around the world to care for children and adults in all countries who face this disease.

“Diabetes threatens to subvert global economic advancement by both straining government budgets worldwide...and burdening private health insurers and employers with spiraling health care costs.” From the World Diabetes Day resolution, passed unanimously by Congress, authored by Reps. Don Payne (D-NJ) and Don Manzullo (R-IL) and Sens. Debbie Stabenow (D-MI) and Pete Domenici (R-NM)

#3+82482?$4+,0@0>.?4@<>?+?29+6?@3+@?C0?+66?800/?@9?07,=+-0;?*34>?/4>0+>0?3+>? ?????@+508?=99@?48?7466498>?91?1+74640>.?,A@?4@?-+8?,0?7+8+20/;;;+8/?0B08??:=0B08@0/; ????????????????%B0=E?2080=+@498?3+>?+?=0>:98>4,464@E?@9?@0+-3?@30?80D@?+,9A@?@30?/+820=>?91???????? ???????????????????????????????/4+,0@0>.?+8/?@9?500:?@34>?0:4/074-?1=97?2=9C482?+8E?1A=@30=; ? ? ???"8/?4@?>@+=@>?C4@3?E9A=?1+746E.?+8/?C4@3?7480;?(948?70.?)9B9?)9=/4>5. ???????????????????????????+8/?@30?%8@0=@+48708@?'8/A>@=E?&9A8/+@498?@9?-3+820?/4+,0@0>; *9?60+=8?79=0.?692?98?@9?CCC;$4+,0@0>"C+=0;-97 "4&%2#..(*-)2$0/'2-%3*.-%+2%,&%11%(.0

,13%30(+,14(0('340%'(.%0-3/*3 #/6/3#/0',1-3"2$3&3577)