D iabetes is not only a devastating disease, it’s an epidemic that now affects more than one in five older Americans and it’s also extraordinarily expensive. The cost of caring for people with type 2 diabetes increased 32% from 2002 to 2007, when estimated diabetes expenditures in the US totaled $116 billion in direct medical costs and $58 billion in indirect costs (disability, work loss, premature death). This is 10% of all dollars spent on health care in the US, with expenditures for people with diabetes more than two times higher than health care expenditures for those without diabetes.

This news is particularly unwelcome in a shaky economy where consumers already worry about the cost and availability of health care. A new Kaiser Family Foundation poll reports that half of American households cut back on health care due to financial concerns in the past year, with 16% reporting having delayed treatment for serious health problems -- for instance, foregoing doctor’s visits for chronic illnesses like diabetes.

IT’S WORSE THAN IT LOOKS...

What we’re seeing today is just the tip of the iceberg, warns global economist and nutritionist Barry Popkin, PhD, director of the University of North Carolina’s Inter-Disciplinary Obesity Center. Diabetes was the seventh leading cause of death listed on US death certificates in 2006, a number he says is, in all probability, "grossly understated" given the rapid changes in diet and body composition of the average American.

Meanwhile, instead of focusing on prevention of diabetes, which is eminently doable for most, mainstream medicine continues to emphasize delivery of more costly crisis management treatment, with an array of pills and insulin that help control but do not cure the disease. Insurance companies are more likely to pay the exorbitant cost of treating devastating complications, such as blindness or kidney damage, and for expensive heart surgeries and amputations, than to pay the relatively modest cost of rigorous disease management or prevention with programs such as fitness trainers and nutritional education. Doing so would save not only money, but also time and suffering. This short-sighted strategy backfires, individually and for our health care system as a whole, warns Dr. Popkin.

DOES PREVENTION MAKE A DENT IN THE PROBLEM?

According to the US Centers for Disease Control and Prevention, prevention really does work:

• In the Diabetes Prevention Program study, lifestyle interventions reduced diabetes development in people at high risk by 58% over a three-year period -- and an even more impressive 71% in adults age 60 and older. In contrast, Metformin, the diabetes drug compared in this study to the lifestyle intervention, reduced diabetes risk only half as much. 

• Comprehensive foot care programs can reduce amputation rates by 45% to 85%.

• Blood pressure control reduces the risk of heart disease and stroke in people with diabetes by 33% to 50%, and the risk of microvascular complications (eye, kidney and nerve diseases) by approximately 33%.

• Lowering blood pressure can reduce the decline in kidney function in people with early diabetic kidney disease 30% to 70%.

• Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by about 50% to 60%.

• Controlling LDL cholesterol can reduce cardiovascular complications by 20% to 50%.

The CDC states that interventions to prevent or delay pre-diabetes from progressing to type 2 diabetes can be feasible and cost-effective. Dr. Popkin and I discussed how to shift the medical paradigm from one that responds to crises to actually preventing them.

WHAT MUST CHANGE

It’s boring to repeat the same advice over and over, but the way to solve the diabetes problem actually has little to do with medical professionals or procedures. It has to happen at home. Americans at risk must solve their weight problem. A leading risk factor for type 2 diabetes is obesity -- one-third of American adults are obese and 17% of children are overweight or obese. Dr. Popkin’s book, The World Is Fat, describes how our lifestyle changes since World War II have created the double epidemics of obesity and diabetes. We need to establish healthier eating habits and exercise programs, specifically...

Limit sodas and snacking. Food and beverage companies sell an ever-growing number of high-calorie soft drinks and sweetened teas, sugary fruit juices, vitamin and energy drinks. The top 40% of consumers buying these beverages drink 760 calories a day from them, observes Dr. Popkin. Don’t fall for seductive advertising -- instead drink healthful and calorie-free water, or enjoy a cup of tea or coffee with a bit of sugar, if you must sweeten it at all. Satisfy between-meal hunger by snacking on an apple, a few walnuts or a handful of baby carrots instead of grabbing processed snacks, even such so-called healthy ones as granola and energy bars, which Dr. Popkin points out are often packed with calories and fats.

Monitor portion control. At Cornell University, 85 nutrition experts were invited to an ice cream social where they were given bowls of different sizes. Interestingly, the experts who got the larger bowls served themselves nearly a third more ice cream. The moral: Keep a close eye on portion sizes. Use small plates and choose reasonable serving sizes. If you’re eating meat for example, this means three ounces (the size of a deck of cards) rather than the usual eight or more.

Establish ground rules before you eat. In a recent study of all-you-can-eat Chinese buffets, researchers found that overweight or obese diners more often choose large plates, chew less and eat everything they served themselves, which can lead to overeating. Especially if you are eating out, set ground rules beforehand to make sure you’re conscious of what and how you eat. For example, decide in advance that you will have water instead of soda... forego dessert... have salmon instead of prime rib... take your time eating... and request a doggie bag instead of cleaning your plate.

GET MOVING

Our armchair-and-TV culture is a major factor in the diabetes epidemic, with fewer than one-third of American adults engaging in regular leisurely physical activity. Indeed, one study found every two hours of TV watched each day is associated with a 14% increase in diabetes. Fortunately, most of us already own the solution -- a pair of sneakers. You don’t have to join a gym or work up a heavy sweat. The research suggests that 43% of new cases of type 2 diabetes may be prevented by 30 or more minutes of brisk walking a day and less than 10 hours of TV viewing a week.

PRACTICE GOOD DIABETES SELF-CARE

If you are at high risk for diabetes or already have the disease, take aggressive steps to control it. Working with your medical team, carefully monitor and manage levels of blood glucose, blood pressure and blood lipids, and stay on top of other preventive care practices (e.g., foot exams and eye screening), all of which help prevent potentially severe complications. If your doctor has prescribed insulin or other medication, take it exactly as prescribed and do not skip doses.

Individually, people pay an enormous price -- physically, emotionally and financially -- for lifestyle decisions that have brought on diabetes. Our national budget is taking a beating as well. It’s in everyone’s best interest to bring this disease under control.