Lifestyle changes are key to California’s diabetes crisis

March 21--Even for those who have worked decades to fight the spread of diabetes in the United States, last week's news was something of a stunner.

In California, more than half of all adults -- 55 percent -- are considered diabetic or prediabetic, according to a UCLA Center for Health Policy Research study released this month. Even more worrisome, those afflicted are getting younger, with roughly one in three adults ages 18 to 39 considered prediabetic -- a danger zone that means they're at major risk of developing life-threatening Type 2 diabetes.

"This is the iceberg," said Ann Albright, director of diabetes programming at the Centers for Disease Control and Prevention in Atlanta. Albright made her comments while in Sacramento last week for a statewide conference on prediabetes that drew about 140 doctors, researchers and government and public health officials.

By 2020, Albright said, experts predict that one in five U.S. adults will have diabetes, double the current number. "That trajectory is frightening," she told the audience. "They are walking toward the cliff's edge."

The frustration, said researchers, is that most people actually have a choice when it comes to diabetes. Unlike many diseases, Type 2 diabetes is largely preventable. Decades of clinical studies have shown "lifestyle changes" -- primarily shedding some weight and getting more exercise -- are extremely effective in preventing or delaying the onset of Type 2 diabetes.

And yet so many Americans seem unable or unwilling to adjust their habits. Why?

Deborah Greenwood, program director for Sutter Health's diabetes education network, is among the experts who point to a culture saturated with cheap, processed foods, whether in vending machines, fast-food outlets or grocery aisles.

"The environment doesn't make it easy to make choices around physical activity and food, when you're faced with so many high-calorie, high-carbohydrate, inexpensive options," said Greenwood, a past president of the American Association of Diabetes Educators.

Even for those who want to make changes, she said, it can be extremely tough to break habits ingrained since childhood.

"The way we live and eat is a habit, and you can't break a habit in a short period of time," Greenwood said. "The research shows it takes about six months for some behavior changes to become a new habit."

In some cases, those habits are seemingly hard-wired into us. "As mammals, we are programmed to like sugar, fat and salt in every possible way," said Harold Goldstein, executive director of the California Center for Public Health Advocacy, which co-sponsored the UCLA study and hosted the Sacramento conference.

Surrounded by super-sized, sugary options at every turn, "for us to say 'No' to those time and time again is against our basic nature," Goldstein said.

Unlike Type 1 diabetes, which is typically genetic and not considered preventable, Type 2 diabetes can generally be avoided with an improved diet and increased physical activity. It tends to hit older adults and is more prevalent in certain ethnic groups, including African Americans, Latinos and Pacific Islanders.

Untreated, Type 2 can lead to a host of life-threatening complications, including blindness, heart and kidney disease and lower limb amputations.

Maria Ibarra knows that reality. Six years ago, at age 35, she was diagnosed with diabetes, a disease that has rippled through her family with devastating consequences. Her youngest brother is blind, and her aunt had a lower leg amputated, both as a result of diabetes. Other family members have had major health complications related to the disease.

Ibarra started taking medication but initially didn't pay too much attention to her diagnosis. When her blood glucose levels crept higher, her doctor recommended a six-week series of classes that offered instruction on nutrition, blood-glucose monitoring, physical activity and one-on-one counseling. Eventually, she joined a Sutter Health study that required her to check her blood-sugar levels before and after meals. It was a shocker.

"When I first started (daily monitoring at meals), my glucose was 189. I could not believe it. That was the first time I was genuinely scared," said Ibarra, who lives in Citrus Heights with her two teenage daughters.

That's when she started making changes and paying attention to what she ate. She noted that when she ate a flour tortilla, her sugar would skyrocket. "When I changed it to a corn tortilla or (flatbreads) made of whole wheat, I noticed my sugars were much more controlled. ... It wasn't until I started testing that I learned how food affected my glucose numbers. I realized that what I ate really mattered."

Slowly and tentatively, she also started to get more physically active. "I won't lie. When I started, I struggled to walk for 10 minutes," she said. Gradually, she stretched her time and distance, and eventually signed up for -- and finished -- a 5K walk.

"Change is one of the hardest things to do when it's not how you were raised," Ibarra said. "I'm Mexican, and in my culture ... exercise wasn't something we did."

Today, exercise and healthy eating are ingrained in her daily routine. She walks during her lunch break at her job as a medical records specialist. She adds black beans as protein to her taco salad, rather than preparing them as a heavy side dish. On weekends, she and her daughters wash, chop and bag fresh fruits and vegetables for grab-and-go lunches at school or work. Instead of high-sugar specialty coffee drinks, she takes her coffee plain with a sugar-free creamer.

Ibarra said the changes were hard but also empowering. "I wanted to be an example to my daughters. I may have diabetes, but it doesn't stop me from living a healthy life."

For years now, the CDC and National Institutes of Health have touted "lifestyle change" programs clinically proven to help prevent the onset of diabetes.

Albright, who runs a CDC division focused on translating research into practice, said there are more than 800 organizations, 50 commercial health plans and numerous states that offer programs recognized by the CDC under the National Diabetes Prevention Program.

"We would love for California to come on board as well," she said.

According to a 2015 state auditor's report, California ranks last in the nation in per capita funding for diabetes prevention. The state spent 3 cents per person in 2012 -- and that's only federal dollars, since California does not allocate state funds for diabetes prevention, the auditor's report noted.

The auditor chided the state for its lagging efforts, calling diabetes a "growing epidemic" that costs California an estimated $27.5 billion a year in health-related costs. The state Department of Public Health "has not been able to expand its diabetes prevention activities to many of the counties ... that have a high prevalence of diabetes," the report noted.

That lack of state effort frustrates those on the front lines of the fight.

"California is putting zero dollars into diabetes prevention. If we're not pissed off, there's a problem," said Tom Boyer, government affairs director for Novo Nordisk, a health care company that provides diabetes care, speaking at last week's conference. "Government is not stepping up to do its job."

Goldstein, of the California Center for Public Health Advocacy, said it's time the state invested in the problem. "The tsunami of diabetes is on its way. It's time to act."

He and others have called for more blood screening, expanded insurance coverage of diabetes prevention programs, and more state and local policies to reduce consumption of sugary drinks, including a soda tax. Goldstein also sees the need for a statewide prediabetes education campaign, akin to the anti-tobacco campaign of the 1990s that led to dramatic drops in smoking and lung cancer deaths.

The state Department of Public Health defended its efforts, saying in an emailed response that it is using "appropriate and available federal funding to implement programs that address strategies reducing the burden of prediabetes and diabetes."

Many health professionals are hopeful that the alarming headlines and continuing research will result in more funding, as well as prod more people into healthy habits.

Greenwood, who has worked on diabetes issues for nearly 40 years, said she senses a shift in awareness and a willingness to increase prevention efforts, partly because federal reimbursements under Medicare now are based in part on healthy outcomes, rather than solely on volume of patient visits.

The stakes are huge, she said, especially with prediabetes trending younger.

"When I think of the data on younger adults, that scares me so much. How long you live with diabetes increases your risk of complications. If you can get diabetes at 18, you're going to be at risk of having heart disease at 28."

Claudia Buck: 916-321-1968, @Claudia_Buck

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