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The Best of Times, the Worst of Times: Now Is the Time

Editor’s note: This article is adapted from the address of the American Diabetes Association President, Health Care and Education, given in June 2002 at the 62nd Annual Meeting and Scientific Sessions in San Francisco, Calif.

This is a remarkable moment in time for diabetes care. We are facing the best of times in many respects, but also the worst of times in some others.

During my term as American Diabetes Association (ADA) President, Health Care and Education, I have seen the treatment of diabetes become increasingly sophisticated. Diabetes research has resulted in newer insulins, better insulin delivery systems and self-monitoring of blood glucose, and increased success of pancreas and islet cell transplantation. Recognition is growing by health care providers, legislators, public policy makers, and businessmen that diabetes is a serious disease.

Senior public health policy makers, such as Allen Speigel, the director of the National Institute of Diabetes and Digestive and Kidney Diseases, and Health and Human Services Secretary Tommy Thompson, are recognizing the cost of diabetes in both human and economic terms and are making diabetes a national priority.

Media attention to diabetes is at an all time high. This year, diabetes has been featured as a major story in dozens of publications and programs, including news magazines Time, Newsweek, and U.S. News & World Report; national newspapers USA Today and The New York Times; and television news programs on networks such as CNN, NBC, and MSNBC. ADA has also been invited to participate in dozens of press conferences receiving national coverage.

A highlight this year has been the announcement of the results of the Diabetes Prevention Program (DPP), which provided very hopeful news that lifestyle change is effective and that type 2 diabetes can be prevented. This spring, we created the term "pre-diabetes" to convey to the media and the public the seriousness of this condition. The challenge is now ours to bring this condition to life, to create opportunities for teachable moments where we can, and to convey a positive, hopeful message that diabetes is preventable.

In the research arena, federal dollars have increased every year in recent times, but allocations still fall terribly short in proportion to the skyrocketing incidence of this disease. Since 1980, the proportion of the National Institutes of Health budget devoted to diabetes research has dropped by 20%, whereas deaths due to diabetes have increased by 40%. Funding will fall further behind recommended levels in coming years unless extra appropriations are made to meet the challenge of the diabetes epidemic.

ADA is committed to supporting diabetes research, allocating one out of every three dollars spent to that cause. The ADA Research Foundation has raised $8 million this year. The response from health care professionals throughout the diabetes community has been tremendous.

Clinical care for diabetes now has more pharmacotherapeutic options than ever before, and many more are in the pipeline. Diabetes education increasingly is being recognized as an integral part of diabetes treatment, as evidence continues to accumulate that diabetes education makes a difference.

Let me tell a personal story about that. I recently received a call from Joe, a patient who had been diagnosed with diabetes 2 months previously and had come to us for diabetes education having already been started on an oral agent and having a hemoglobin A1c (A1C) of 11.1%. Joe and I had had several face-to-face and telephone contacts, and he had been working on his lifestyle changes. This time, he was calling to say he had been taken off his oral medication 1 month ago, and his A1C was now 6.9%. Does diabetes education make a difference or what?!

Yet the sad fact remains that only about 30% of patients with diabetes have received any education on any diabetes-related topic, according to recent telephone surveys by the Centers for Disease Control and Prevention (CDC). We have so much work left to do on this. Every time I have talked to members of the media this year, this was a message I gave them.

Another piece of good news that came this year was that, for the first time ever, registered dietitians became the official providers of medical nutrition therapy to Medicare recipients. This was a landmark step toward providing the comprehensive treatment that people with diabetes so deserve.

ADA lobbied hard for this in tandem with the American Dietetic Association and the American Association of Diabetes Educators (AADE). We are delighted that our opinions were heard and woven into the final regulations. Very soon, you will be able to pull up six newly created documents about how to use the new nutrition guidelines on the websites of four major diabetes organizations: ADA, AADE, the American Dietetic Association, and its Diabetes Care and Education practice group.

Yes, our partnerships with other diabetes organizations are stronger than ever. This year, ADA helped AADE to develop the new Board Certified–Advanced Diabetes Manager credential. This advanced practice credential for nurses, dietitians, and pharmacists promotes visibility for and awareness of the important roles non-physician health care providers play in diabetes care.

ADA’s advocacy efforts are also as aggressive as ever and continue to focus on championing adequate funding for diabetes research; improved reimbursement for diabetes education, equipment, and supplies; the rights of children with diabetes in schools; and the elimination of discrimination against people with diabetes in all settings.

Despite these successes, however, we are now facing the worst of times in some other respects.

The CDC has labeled diabetes an epidemic; newly released figures indicate that 17 million Americans suffer from this disease, and another 16 million suffer from pre-diabetes. Diabetes in America jumped 50% during the decade between 1990 and 2000. By 2010, 10% of the adult American population is expected to have the disease.

Despite all the advancements in diabetes care, normal blood glucose for any appreciable time is seldom achieved, serious complications still occur, and the huge economic and personal burden remains. Further-more, a recent market survey showed that 68% of people with diabetes do not consider cardiovascular disease to be a serious complication of diabetes nor do they feel at risk because of their high blood pressure or cholesterol levels.

Besides the diabetes epidemic, the other epidemic I’m passionate about is obesity. Although we have made dramatic progress in recent decades in achieving many health goals, the statistics on overweight and obesity have steadily headed in the wrong direction. Obesity and overweight are the most prevalent nutritional disorders in the United States, affecting 61% of adults and 13% of children. This represents a 60% increase in obese Americans and a threefold increase in obese children since 1980. There are now as many obese people in the world as there are people suffering from hunger. Projections are that by 2007, 75% of Americans will be overweight or obese.

Former U.S. Surgeon General David Satcher issued a call to action to prevent and decrease obesity, stating that health problems related to overweight and obesity could reverse many of the health gains in the United States in recent decades. He further warned that obesity may soon surpass smoking as the nation’s No. 1 cause of preventable disease and death.

However, a study just released suggests that only one-third of Americans see obesity as a major public health problem, and 65% of those surveyed blamed obese people for lacking the willpower to diet and exercise.

As a nation, we must respond as vigorously to this obesity epidemic as we do to an infectious disease epidemic. National efforts are needed to encourage physical activity and better educational, behavioral, and environmental approaches to control and prevent obesity. Five key settings have been identified for activities and interventions: families and communities, schools, the health care industry, media and communication, and worksites. Experience has shown that focusing on the young may be our best bet.

The message is clear: eat healthy foods and be physically active. Sound simple? Well, it is not simple at all, as we all know only too well. The first problem is that the average American does not know what a single portion is. The second problem is that, even those who do know what appropriate portion sizes are find translating the knowing into doing to be a major challenge.

Obesity is increasingly viewed as a complicated interplay between genes and environment. Studying the genetics of obesity will help lead us to a greater understanding and help us explore new options for prevention and treatment. Appreciating the importance of genetics helps to dispel the all-too-common notion that obesity represents an individual character defect or moral flaw. It is time to stop blaming the victim. If we, the diabetes experts, don’t offer treatments that are safe and effective, we are abandoning our patients when they need us the most and inviting them to turn to the latest fad diets promoted widely in the media.

So, in light of where diabetes care is today, what is ADA doing this year to prevent diabetes and to improve the lives of all people affected by diabetes? This year, ADA staff and volunteers have accomplished many successes, which I think we should celebrate with great pride. Let me name just a few:

• ADA has continued to fund the best science, substantially increasing support to awards that will nurture the careers of scientists most likely to make a difference in our understanding of diabetes.
  
• ADA has taken a huge step forward in type 1 diabetes research this year with the Newborn Screening Initiative. This 5-year study funded by the ADA and the University of Florida is the first ongoing statewide program to determine a child’s genetic susceptibility to developing type 1 diabetes. It represents the largest single research funding commitment in ADA history.
  
• ADA continues as the leader of the scientific and research community by hosting its annual Scientific Sessions, the world’s largest scientific conference on diabetes.
  
• In January 2002, ADA published "Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Comp-lications." This updated position statement includes an expanded section on energy balance and obesity and includes for the first time a section on prevention. These recommendations received widespread media attention and led to a feature article in The New York Times, which was then picked up by many other media outlets and Internet sites.
  I found myself very busy then, and whether I was talking to Jane Brody of The New York Times or Anita Manning of USA Today, my message was the same: Medical nutrition therapy is effective when used appropriately. But eating healthy in today’s environment is like swimming upstream. Most people need help. People with diabetes deserve to be referred to a registered dietitian or diabetes educator who is trained to help.
  
• Soon, there will be an array of updated meal planning materials for patients from ADA and the American Dietetic Association.
  
• This spring, ADA published a position statement reviewing the clinical implications of the recent prevention trials and setting out recommendations for screening and intervention. Prevention was a key topic at this year’s Scientific Sessions in San Francisco. ADA is moving quickly to incorporate the DPP prevention messages into all of its community programs and events. And I am proud to say that I am a co-author of 101 Weight Loss Tips for Preventing and Controlling Diabetes, the first ADA book incorporating the diabetes prevention message.
  
• We are also becoming involved in advocating to create healthier environments and lifestyle choices for our nation’s children. I had the opportunity to visit the Illinois Capitol twice this spring to testify about the need to retain physical education in schools and to stop giving waivers to anyone who wants to opt out of this class.
  
• In the area of obesity, ADA has received a $1 million grant to develop an obesity education initiative directed at both health care professionals and consumers.
  
• ADA is nurturing its relationship with the North American Association for the Study of Obesity (NAASO), and plans are underway for a joint sponsored conference next year.
  
• We have partnered with the National Diabetes Education Program and the CDC to promote "The ABC’s of Diabetes"—(A1C, blood pressure, and cholesterol) to the media and to people with diabetes.
  
• We also partnered with the American College of Cardiology, with generous support from many industry sponsors, in our "Make the Link" initiative urging people with diabetes and health care providers to make the link between diabetes and heart disease and stroke.
  
• We also worked with the Food and Drug Administration’s Office of Women’s Health and the National Association of Chain Drug Stores on public awareness activities targeting women with diabetes. This campaign, called "Take Time to Care—About Diabetes," was launched in May in 3,000 retail pharmacies across the country.
  

This has been a wonderful year of successes and challenges, and it has indeed been my honor to serve as one of the principal officers of ADA. In many ways, medical nutrition therapy has been a hot topic this year, so I was especially glad to be a registered dietitian serving in this role at this moment in time.

Now, for just a few final thoughts. I have spent my term as President, Health Care and Education, watching, learning, pondering, mentoring, and just plain living. Many times I’ve thought about how and why I got here, to this awesome position. I am passionate about diabetes. Every day, I see the devastation that diabetes causes in the lives of my patients and their families. I want to see diabetes prevented. I want there to be better ways to care for people with diabetes.

But why have I chosen for 25 years to spend my after-hours time, evenings, and weekends volunteering for ADA and other causes that benefit people with diabetes? Why has diabetes become not just my job, but my vocation?

I truly believe that we can make a difference. But it’s more than that. For me, it’s all about relationships. It’s the relationships with ADA staff, with other volunteers, and even with my patients that have kept me involved and always coming back for more. Some I’ve met and known only for the duration of a single project; others I’ve known and worked with repeatedly over many years.

As an ADA volunteer, I have discovered a world beyond my home base and met ADA volunteers and staff who do amazing things. Many of these same people have helped me do amazing things—things I would never have predicted I’d do—such as chair six gala fundraising events or testify in front of the Illinois House and Senate, or do live media interviews at a moment’s notice.

Working with ADA adds credibility to our work because ADA’s name and logo are synonymous with accurate, consistent, relevant, and timely information. My ADA work has certainly enriched the skills and interests that I take back to my workplace and my patients.

I love my work with ADA, but more than anything, I hope I have modeled for our three beautiful children what it means to identify what you like to do, do your best to become good at it, and work to make the world a better place for others.

To me, ADA is my ADA, it is your ADA, and it is our ADA. We health care professionals are integral to every aspect of the ADA mission. I’d like to reach out and ask you all to become involved and to become leaders, if you are not already. Consider the following as goals for yourself:

1. Find one other health care professional—someone you identify, recruit, train, and retain—to become active in your area in the ADA mission to find a cure for diabetes. We need new health care professionals at the community level. This is where grooming, mentoring, and fostering future leaders needs to start.
   
2. Step out of your usual comfort zone to participate in a fundraising activity in your area if you do not already. Choose something that feels doable for you, such as recruiting a team for America’s Walk for Diabetes.
   
3. Get involved with advocacy. Make an appointment with your representative or senator to talk about how federal dollars for research are allocated and why diabetes doesn’t get its fair share.
   
4. Offer your professional skills for a community professional or public education event already planned in your area. If there isn’t one planned, start planning one.
   

Whatever you do, find a niche that fits you and your interests. ADA needs you, and the time is now.

Footnotes

Anne E. Daly, MS, RD, BC-ADM, CDE, is director of nutrition and diabetes education at Springfield Diabetes and Endocrine Center in Springfield, Ill. She is the immediate Past President, Health Care and Education, of the American Diabetes Association.

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