By Shawn Shepherd
Illustration by Malcolm Garris/PhotoDisc
January 25, 1999

A disease that experts say has been in the closet too long is on its way to becoming an epidemic. While the population ages and too many lead sedentary lifestyles leaving themselves at risk for the chronic illness, the costs of treating diabetes weighs on an already stressed healthcare delivery system, experts say.

The prevalence of diabetes is increasing at an alarming rate, public health officials say. Most experts agree that the risk factors for diabetes—obesity, lack of exercise, and longer life spans—are reasons the disease is appearing in more patients in this country.

Sudden increase

National Centers for Disease Control and Prevention (CDC) statistics show there are now 15.7 million Americans diagnosed with diabetes, and another 5 million who may be unaware they have it. The numbers represent a dramatic increase since 1958, when the CDC reported 1.6 million cases.

"An epidemic is a sudden increase in a disease rate beyond an expected level," said Michael Stern, MD, a professor of epidemiology at the University of Texas at San Antonio, "and that is what’s happening with diabetes." Stern is one of the authors of a 20-year epidemiologic study conducted in San Antonio that shows diabetes has increased threefold since 1979.

At-risk populations

Among the communities most at risk, according to researchers, are minorities. Leading in those numbers are Hispanics, who experts say are twice as likely to have diabetes as non-Hispanic whites of similar age.

The rate of diabetes among Mexican-Americans is 55 percent higher than among other Hispanics, according to Wilma Ramirez, RN, the diabetes education coordinator for Southwest General Hospital in San Antonio. While some researchers attribute this to genetics, Ramirez said lifestyle puts Mexican-Americans at greater risk.

"The main factor is diet and lifestyle," Ramirez said, "most [Mexican-Americans] have a diet high in fat and starches and a sedentary lifestyle, and that’s very difficult to change."

"Diabetes is such a mystery, and we need to target many of our educational and research efforts to help people at risk get quality care," said Luckner C. Denord, MD, community health adviser for the Hispanic Health Council.

"There are so many cultural barriers that contribute to the prevalence [of diabetes among Hispanics]," Denord said. "They can’t afford nutrition, do not know about diabetes, and don’t exercise." Southwest General Hospital has one of the nation’s leading diabetes outreach programs. The community-based education program is one of more than a dozen diabetes prevention efforts in the city.

Prevention is key

The 11,000 active members of the American Association of Diabetes Educators (AADE) believe education is the best course to reduce incidence of the disease.

"The bottom line is that good glycemic control does in fact reduce, prevent, or delay many of the devastating complications of diabetes," said Christy L. Parkin, RN, a private consultant and an AADE board member. Parkin cites blindness, kidney disease, and nerve damage as the most deleterious complications. "One of the most important things for the [educator or healthcare provider] to do is to get the patient to understand the process of diabetes," Parkin said. "A well-educated and motivated patient is far less likely to experience complications."

According to the National Institutes of Health’s Diabetes and Digestive Kidney Diseases Division (DDKD), there are 21 million Americans at risk for type 2, or adult onset, diabetes.

"Prevention is the key here, particularly with type 2 diabetes," said Judy Fradkin, MD, deputy director of diabetes, endocrinology, and metabolic diseases at the DDKD. "Healthcare professionals have to inquire about family histories and take a second look at those in the risk groups."

Testing access

In addition to education and lifestyle changes, experts say diabetes management requires testing. To increase testing, the American Diabetes Association (ADA) developed a protocol in 1997 allowing at-risk patients to be screened by a fasting blood sugar test, rather than the more time-consuming and costly glucose tolerance test. Under the new guidelines, patients with a glucose level of 125 are considered likely candidates for type 2 diabetes. But not all at-risk patients have ready access to screening, say advocates.

"Limited access to medical care makes [diabetes complications] even worse," Ramirez said. "Often they have never been diagnosed with diabetes, and by the time they get health care, they’re having real medical problems."

Diabetes treatment is also taking its toll on the healthcare system, experts say. The advanced medical problems many diabetic patients experience—such as blindness, arterial damage, cardiovascular problems, circulatory problems, and kidney disease—are a cost factor that must be considered. Statistics show diabetes patients are more likely to develop complications that require care, including extended hospitalization.

The ADA estimated that direct medical costs for diabetes amounted to $44.1 billion in 1997, and indirect costs attributed to disability and mortality exceeded $54 billion. In addition, the ADA estimates that the total healthcare expenditures of diabetes patients neared $78 billion.

"There are two aspects of the cost of diabetes," Fradkin said. "There are the healthcare costs associated with the care of diabetes patients, and then there are the costs associated when people develop other problems."