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.