An Ounce of Prevention: Controlling the Diabetes Epidemic

Epidemics used to be infectious, sweeping across cities and nations, immediately producing violent symptoms in their victims, and often followed promptly by death. They instilled fear in the public and the urgent need for a solution would be unanimous, unquestionably a public health priority. Modern epidemics, on the other hand, tend to be noninfectious and often sneak up slowly. Their symptoms may be mild for years and persist through old age, redefined as “chronic conditions,” until they finally kill their victims. Their incidence and fatality are often preventable.

One such epidemic is diabetes. It’s been creeping up on us for over two decades, and yet any sense of urgency in quashing it is still minimal, although it is growing. Diabetes is the seventh leading cause of death, costing billions of dollars a year, with no sign of slowing down and no sign of a cure. It poses a particular challenge in a time when cuts in health care costs are needed: should it be made an exception to the necessity of cuts in general?

Approximately 19 million Americans are diagnosed with diabetes and nearly 79 million adults are prediabetic, meaning that they have blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetic. The annual cost of diabetes is over $218 billion. The American Diabetes Association projects that the cost of diabetes and the number of people with the disease will at least double over the next 25 years.

Obesity, Aging, and Longevity

The diabetes epidemic parallels the obesity epidemic: 90% to 95% of cases of diabetes are type 2, which is caused partly by obesity. About 80% of type 2 diabetes patients are overweight or obese. Experts identify obesity and type 2 diabetes as two of the greatest public health problems of the coming decades in the U.S. and globally.

The prevalence of diabetes also increases with age, and the U.S. population is aging. But it is on the rise among young people, as well, mainly because of obesity.

Until the mid 1990s, children and adolescents rarely developed type 2 diabetes, which had been call “adult-onset” diabetes. Today, the Centers for Disease Control and Prevention estimates that type 2 diabetes is diagnosed in 3,700 children annually. Furthermore, a recent study found that the prevalence of prediabetes is almost 30% among overweight and obese children in high-risk communities across the nation. “High-risk” refers to groups that are disproportionately affected by diabetes, including Hispanics, blacks, and Native Americans. 

The diabetes epidemic is also, in a sense, a reward for effective treatment. People are living longer than ever with diabetes in large part because improved treatments. As the disease progresses, however, patients often need additional medications and increased dosages to keep their blood sugar within safe ranges. They also develop complications. Diabetes is responsible for more cases of blindness, renal failure, and amputations than any other disease and increases the risk for cardiovascular disease and stroke by two– to fourfold. 

Opportunities for Savings

Comparative effectiveness research at Johns Hopkins determined that metformin, a generic drug that has been around for more than 15 years, is as effective for reducing blood sugar levels as newer drugs, has fewer side effects, and is the cheapest oral medication (35 cents per pill, compared with as much as $6.42 per pill for newer drugs).

Nevertheless, the most significant savings lies in prevention. Type 2 diabetes is largely preventable. The Diabetes Prevention Program, the largest and most diverse prevention trial to date, compared the cost-effectiveness of the metformin and lifestyle intervention in preventing prediabetic adults from developing type 2 diabetes or delaying onset. Lifestyle intervention proved to be the most effective means of preventing diabetes, reducing onset by 58%. Metformin reduced onset by 31%. Researchers determined that the cost of lifestyle intervention implemented in routine clinical practice would be $13,200 per case of diabetes delayed or prevented over three years – a savings of $1,100 compared to medical intervention.

Last January, a study published in Diabetes Care found that 24 million of America’s prediabetics might benefit from pharmacological treatment (in addition to lifestyle modification) to prevent or delay development of diabetes. According to the study, the cost of 24 million new prescriptions of metformin, at current generic rates, would be about $1.15 billion per year, plus related medical expenses such as doctor’s visits and laboratory tests. 

That’s a lot of money, but it’s worth it in the long run. Though other modern epidemics, like cancer and cardiovascular disease, continue to surpass diabetes as the leading causes of death in the U.S., their incidences are on the decline, while the incidence of diabetes is on the rise. The diabetes epidemic is set to hit future generations harder than ever. Experts predict that today’s children could be the first generation to have shorter and less healthy lives than their parents.

In the midst of the economic crisis in health care it may seem implausible to increase health care spending to cover the upfront costs of diabetes prevention such as screening, treating prediabetics, and reducing obesity. The cost of prevention will be substantial, but the nature of the diabetes epidemic warrants this sort of investment because the future, if left to follow the current path, is sure to exceed the cost of prevention by far.

Brittany Rush is a former Hastings Center visiting scholar.

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