William Herman has spent decades researching diabetes, treating patients grappling with complications from it and trying to educate people on how to prevent it. During those same years, he also has seen the prevalence of the disease grow virtually unabated.
“It really is an epidemic, both in the U.S. and globally,” said Herman, director of the University of Michigan’s Center for Diabetes Translational Research and a consultant to the World Health Organization.
The statistics are staggering. More than 29 million Americans, or 9.3 percent of the U.S. population, have diabetes — but a quarter of them don’t yet realize it, according to the Centers for Disease Control and Prevention. An additional 86 million Americans have pre-diabetes, which is marked by higher-than-normal blood-sugar levels and puts them at an elevated risk of developing diabetes. The WHO estimates that nearly 350 million people worldwide have the condition.
Year after year, diabetes exacts a massive human and economic toll. Those who have it are at a higher risk of heart disease, stroke, kidney failure and blindness, and of losing toes, feet and legs to amputation. The risk of death for adults with diabetes is 50 percent higher than it is for adults without the disease, according to the CDC.
“The costs of diabetes are enormous, and they are growing,” Herman said. “People with diabetes account for a substantial portion of the total cost of health care in the United States.”
Medical expenses tend to be twice as high, on average, for people with diabetes than for those without the disease. Collectively, it costs the U.S. health system an estimated $250 billion a year, including major amounts of lost work and productivity. That includes billions spent on inpatient care, doctor’s visits, medication and supplies such as glucose monitoring strips. The American Diabetes Association (ADA) estimates that treating patients with the disease accounts for more than $1 of every $5 spent on health care in the United States.
“It has affected all segments of the population,” said Edward Gregg, chief of the epidemiology and statistics branch of the CDC’s diabetes division. “But it hasn’t affected everyone equally.”
The risks generally increase with age, but a growing number of people younger than 20 are diagnosed with diabetes. Asian Americans, African Americans, Hispanics and Native Americans all have higher rates of the disease than whites, and those who live in areas of extreme poverty have been hit particularly hard.
The CDC found that diabetes diagnoses increased between 1995 and 2010 in every U.S. state, including by 50 percent or more in 42 states. During that period, the total number of cases in the country more than doubled.
Despite the immense number of people who have diabetes, it has not triggered national alarm. Other illnesses, such as cancer and Alzheimer’s disease, often garner more attention. One reason is that diabetics sometimes go years before experiencing any decline in their quality of life. When complications do surface, they often do so gradually and manifest in various ways. People don’t always recognize diabetes as the source of severe health problems.
In fact, the CDC says diabetes is underreported as a cause of death, even though it is the seventh-leading cause of death in the United States. For instance, the numbers of people listed as dying each year from heart disease and stroke are larger than they are for diabetes but many of those people had diabetes as an underlying condition.
Before the nation can turn the tide of the epidemic, society must recognize diabetes as the pervasive killer it is, said Marjorie Cypress, a nurse practitioner for ABQ Health Partners in New Mexico and president of health care and education for the ADA.
“We have to convince people this is a serious disease,” she said. “It really needs to be a big push on every level.”
The overwhelming majority of diabetes cases — as many as 95 percent — involve the Type 2 form of the disease. It occurs when the pancreas can no longer make enough of a hormone called insulin, and the body cannot effectively use the insulin being produced — a condition known as insulin resistance. The result is a build-up of glucose levels in the blood, which over time can harm the kidneys, eyes, nerves and heart.
Early symptoms can include frequent urination, excessive thirst, persistent fatigue and a tingling or numbness in the hands or feet. Or there may be no symptoms until long after someone has developed diabetes, which is one reason doctors have placed a growing emphasis on early screening.
Although genetics play a role in a person’s risk for the disease, the increase in diabetes diagnoses is largely attributable to lifestyle changes, Gregg said. The disease is closely associated with high blood pressure and cholesterol, poor diets, obesity and a lack of exercise. The good news is that improvements in diet and lifestyle can go a long way toward delaying or preventing the disease. The trick is to help people find effective ways to change their habits.
“Lifestyle interventions have been shown to be very effective when targeted at people with very high risk for diabetes,” Herman said. “The major opportunity going forward is to get those interventions into routine clinical practice.”
Type 1 diabetes is another challenge entirely, and a perplexing one. Once referred to as juvenile diabetes, it is an autoimmune disease that can develop at any age, but typically is diagnosed in children and young adults. It accounts for about 5 percent of all diabetes cases.
With Type 1 diabetes, the body does not produce the insulin needed to convert sugars and other food into useful energy, and in fact the body’s immune system attacks insulin-producing cells, mistaking them for foreign invaders.
It remains unclear what triggers the disease. Evidence suggests that a person’s genetic makeup or environmental factors, such as viral infections, can play a role.
“It still is somewhat of a mystery,” Cypress said. “I don’t think we really know, and that’s probably why we haven’t found something that works to prevent it.”
For now, patients with Type 1 diabetes face a delicate balancing act, continually monitoring blood-sugar levels to keep them from dipping too low or spiking too high. They also must take daily insulin via a pen, syringe or pump, as well as manage the condition through proper diet and exercise.
Despite the decades-long worsening of the diabetes epidemic, the news isn’t all grim.
The fact that more people are being diagnosed has a silver lining: Greater public awareness has led to increased screening.
“That’s a good thing, because they are getting care,” Herman said.
Experts also point to the inroads made by the National Diabetes Prevention Program, a public-private collaboration among federal health agencies, community-based organizations, insurers and other groups that encourages modest lifestyle changes that can prevent or delay the onset of Type 2 diabetes.
The program has taken different forms in different places, but it generally involves teaching people strategies for healthier eating and increased physical activity. For example, YMCAs nationwide have seen results in offering a year-long program in which small groups of at-risk patients meet regularly with a lifestyle coach.
In addition, researchers continue to study the physiology and genetics of the disease. Promising drugs and diagnostics continue to arrive on the market, allowing both Type 2 and Type 1 patients more tools to treat their conditions.
“There’s better comprehensive care. There are better medications. Also, people are better educated; they manage it better,” said Gregg, the CDC epidemiologist. But “because people with diabetes are living longer, once people get diabetes, they are spending a lot more years with the disease.”
Cypress said that real, lasting change will require an even bigger push, the kind of massive effort it took for the country to begin viewing tobacco use as a public health scourge. It will take a fervor that extends to national policies and grass-roots efforts, she said. And, for those with Type 2 diabetes, it will require finding more ways to help people make sustained lifestyle changes, such as getting more healthful foods into schools and underserved communities; encouraging regular exercise among all ages; and relying on teachers, pastors and other community leaders to help spread the message.
“It’s not just one fix. It’s a societal shift,” Cypress said. “We need to create that sense of urgency.”