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.