The most frequently cited evidence is a large clinical trial conducted by the Diabetes Prevention Program Research Group. It randomly assigned more than 3,000 pre-diabetic adults to one of three groups. One group received a placebo, another the oral diabetes drug metformin, which decreases glucose production, and the final group took part in an intensive lifestyle modification program of diet, exercise, and behavior modification counseling aimed at helping them lose 7 percent of their body weight. They were put on a low-fat, low-calorie diet, exercised 150 minutes a week, and sat down regularly with a case manager for one-on-one behavior modification sessions. The results, published in 2002, were impressive: Over nearly three years, people in the lifestyle intervention group were 58 percent less likely to develop diabetes, while those on metformin shaved their risk by just 31 percent.
Battling Diabetes With Diet and Exercise
Prevention and intensive management are the keys to stopping the epidemic
By Michelle Andrews, U.S. News & World Report
Posted October 10, 2008
Diabetes experts from around the world recently gathered in New York City to discuss various techniques that alter patients’ digestive systems to help them lose weight and get their blood sugar under control. One method, gastric bypass surgery, is approved only for weight loss but also short-circuits diabetes in many cases. Another approach—for now, experimental—involves an implanted “smart” gastric band that senses food in the stomach and tightens or loosens its grip accordingly. And a third lines part of the intestine with a gastric “sleeve” that, apparently by interrupting the neural and hormonal communication between the brain and the gut, promotes weight loss and better blood sugar control, similar to gastric bypass surgery. Compared with surgery, the endoscopic insertion through the mouth of this intestinal condom is so patient-friendly, it was suggested, that someday visiting a doctor for periodic replacements might become as routine as getting your teeth cleaned.
While such procedures may seem like extreme measures to counteract overeating and its effects, there’s good reason researchers are investigating them: Existing medical therapies for type 2 diabetes haven’t stemmed the growing obesity-related epidemic, which now affects 24 million Americans. But while gastric bypass surgery, new devices, and medications are important weapons in the fight against diabetes, winning the war requires a broader approach. It means not only treating those who already have the disease but also heading it off in the 57 million Americans whose blood sugar levels put them at risk for developing it. It may seem obvious, but prevention, many agree, is the key to succeeding against diabetes in the long run. “Our only hope is to do prevention,” says John Buse, president for medicine and science at the American Diabetes Association.
Urgent task. The stakes are high and getting higher. The number of people with diabetes has increased 13.5 percent since 2005. At the current rate, 1 of every 3 people born in 2000 will develop the disease, putting them at higher risk of heart disease, stroke, kidney disease, blindness, and nerve damage, among other medical problems. The economic cost of diabetes-related medical care and lost productivity is enormous: $174 billion in 2007, according to ADA estimates.
The diet and exercise changes that are the backbone of prevention are easier to make when neighborhoods and schools encourage them. That’s why health insurer Kaiser Permanente started its Healthy Eating, Active Living (HEAL) program four years ago. “We want to make the healthy choice the easy choice by changing the environment our members live in,” says Loel Solomon, National Director of Community Health Initiatives and Evaluation for Kaiser. The program, now operating in six states, focuses on developing community-based initiatives that promote physical activity and eating well. Measures include ramping up the supply of vegetables in local groceries, improving bike paths and pedestrian walkways, and replacing the sugary sodas in school vending machines.
For the past year and a half, Helen Garcia has been volunteering with the Kaiser-founded LiveWell Colorado program at a middle school and a high school near her Denver home. The program organizes regular walking expeditions for parents around a lake near the school. Meanwhile, students planted vegetables on a vacant plot of land nearby and hold a farmers’ market on Tuesdays to sell their produce to parents and students. Garcia, 60, who was diagnosed with type 2 diabetes nearly 20 years ago, has five grandchildren attending the two schools. “My goal is to make sure they don’t get it,” she says.
That kind of soup-to-nuts community approach has many fans, but more direct interventions are also helpful for people who already have diabetes or are at high risk. The most frequently cited evidence is a large clinical trial conducted by the Diabetes Prevention Program Research Group. It randomly assigned more than 3,000 pre-diabetic adults to one of three groups. One group received a placebo, another the oral diabetes drug metformin, which decreases glucose production, and the final group took part in an intensive lifestyle modification program of diet, exercise, and behavior modification counseling aimed at helping them lose 7 percent of their body weight. They were put on a low-fat, low-calorie diet, exercised 150 minutes a week, and sat down regularly with a case manager for one-on-one behavior modification sessions. The results, published in 2002, were impressive: Over nearly three years, people in the lifestyle intervention group were 58 percent less likely to develop diabetes, while those on metformin shaved their risk by just 31 percent.
Scarce resources. Yet money to implement such intensive prevention programs is scarce. Diabetes receives significantly less funding per patient than many other diseases. The Centers for Disease Control and Prevention, the primary federal agency responsible for preventing both the spread of and complications from diabetes, received $62.7 million for diabetes programs during fiscal year 2008. (Other CDC programs related to obesity may also help prevent diabetes.) By contrast, the CDC spends $309.5 million on cancer prevention, which affects 10.8 million people, and $691.9 million on HIV/AIDS, which infects 1.5 million Americans.
“We as an advocacy community have not been as effective at arguing for prevention as we have been arguing for treatment,” says Georges Benjamin, executive director of the American Public Health Association. Many of those at risk for diabetes look around their communities and believe that contracting it is inevitable, and because it’s such a slow-moving chronic disease, its lethal consequences are too often played down, many agree. What’s more, unlike AIDS or breast cancer, for example, which have vocal, well-educated advocate communities, diabetes primarily impacts people of low socio-economic status, who often find themselves blamed for the obesity that leads to their illness. “People look at it as a question of willpower,” says Louis Arrone, director of the comprehensive weight control program at New York-Presbyterian/Weill Cornell Medical Center.
Skimpy public health funding aside, insurance companies are typically reluctant to pay for prevention efforts. Although insurance covers most of the $3,000 cost of Joslin Diabetes Center’s intensive 12-week Why WAIT program for people with type 2 diabetes, program operators haven’t yet expanded it to people with pre-diabetes because of funding concerns. “Insurers won’t pay for someone to lose weight,” says Osama Hamdy, medical director of the Obesity Clinical Program at Joslin. “They’re shortsighted. They know people will change companies in a year.”
The Why WAIT program focuses on helping patients with diabetes lose weight through exercise, diet, behavior modification, and medication management, taking people off diabetes drugs that cause weight gain in favor of those that help them shed pounds. Researchers recently reported that participants in the 12-week program lost an average 23.5 pounds and reduced their average blood glucose—as measured by A1c levels—from 7.5 percent to 6.6 percent, below the 7 percent target.
Linda Cass, 55, went through the program back in 2005. More than two years later, she’s kept off 11 of the 13 pounds she lost, and her A1c level is at 6.6 percent. Her blood pressure and cholesterol levels are normal. “Now I feel like I have some control over this chronic disease,” she says.
Even though most insurers may balk at covering prevention, some employers with an eye on their healthcare bottom line are stepping up to the plate. A recent Kaiser Family Foundation study found that 23 percent of companies that provided health insurance benefits offered gym membership discounts or had on-site exercise facilities. Fifteen percent offered weight management programs and 14 percent offered classes in nutrition or healthy living. (The foundation is unrelated to Kaiser Permanente.) Employees at food giant General Mills in Minneapolis, for example, can take healthy cooking classes and participate in “Fun Friday” fitness events, among other things. At Pitney Bowes, the mail and document management technology company based in Stamford, Conn., the 6 percent of employees who have diabetes get free blood pressure and cholesterol drugs and pay just 10 percent coinsurance for diabetes drugs. That’s in addition to comprehensive nutrition and exercise programs for all employees.
There is no magic bullet that will win the war on diabetes. Researchers, employers, community advocates, insurers, and, yes, gastric bypass surgeons, all have a role to play. But those efforts will be stymied if average people don’t take prevention to heart. Focus groups show that people don’t think diabetes is a serious problem on the level of cancer or AIDS, says Larry Hausner, CEO of the ADA. To change that, the association is launching a public education campaign in November, timed to coincide with National Diabetes Awareness Month. Advocates point to the antismoking campaigns that began in the 1960s as a model that shows that public health outreach can have a significant impact on people’s behavior. They also note, however, that it took years for those campaigns to have an effect.
Last year, 1.6 million adults were diagnosed with diabetes, or more than 4,000 each day. The clock is ticking.