Billions on treatment, little on prevention

A teenage girl walks the hardscrabble streets of Richmond, a Bay Area city, rapping about the challenges of drugs, violence—and diabetes. Here, she says, big dreams are “coated in sugar,” and innocence is “corrupted with Coke bottles and Ho Ho cupcakes.”

She’s performing in a video by a local youth group that counts diabetes, a national epidemic that has hit California hard, as one of the killers in her neighborhood. Type 2 diabetes, which is spreading and driving up health costs, now impacts more than half the state’s adults, especially people of color and the poor.

Experts say that prevention programs can slow the march of the illness and save money at the same time. But efforts to legislate prevention—for example, by taxing the sugary drinks whose consumption contributes to diabetes—have stalled in the face of heavy opposition by the well-funded beverage lobby.

The state will soon begin funding a program for anti-diabetes education, counseling and lifestyle coaching, but it’s a modest investment regarded only as a start.

“Investing more now in diabetes prevention and education will save our state billions of dollars down the road,” said state Sen. Bill Monning, a Democrat from Carmel who has proposed soda taxes in the past and tried unsuccessfully this year to require warning labels on sweetened drinks.

A UCLA study last year found that 9 percent of adults in California have been diagnosed with diabetes, a chronic condition in which the body does not process sugar well and which can lead to blindness, heart disease, stroke and infections resulting in amputations. Forty-six percent—including about a third of those under 40—are prediabetic, with elevated sugar levels that likely will develop into diabetes. That’s 55 percent of the state’s adult population swept up by the disease.

Treating diabetes costs government, private insurers and patients about $27.6 billion a year in California for such expenses as doctor visits, testing, medication, surgery and hospital costs, according to the American Diabetes Association. The state and federal governments shoulder most of that expense through Medi-Cal, which is California’s health program for those living in poverty, and the national Medicare system that covers seniors.

A state audit of the California Department of Public Health diabetes prevention efforts released two years ago said that California lagged in such spending. The state spent about $1 million from the federal Centers for Disease Control and Prevention, a sum that has since grown to $1.4 million, but did not devote state money to such programs. New York, the audit points out, was spending $7.2 million, although some of that money went to anti-obesity programs.

Beginning in July, with the next budget, $5 million in state funds will go toward a nutrition and exercise program for prediabetic enrollees in Medi-Cal. That project, based on a CDC model called the Diabetes Prevention Program, can cut the risk of developing diabetes in half. In addition, it is expected to save about $45 million in treatment expenses over the next five years, said Assemblyman Joaquin Arambula, a Kingsburg Democrat and physician who co-chairs a health subcommittee.

Flojaune Cofer, an epidemiologist and director of state policy and research for the nonprofit Public Health Advocates, said that about 25,000 people will be able to participate each year.

“We can’t just wait until people get sick because it’s not a viable system,” Cofer said.

Adult diabetes, or Type 2, doesn’t get the same attention as some other deadly diseases, such as cancer. Nor is it considered as blameless as Type 1 diabetes, a childhood disease diagnosed when the body produces little or no insulin, which affects about 5 percent of those with diabetes, according to the CDC.

Type 2 is considered mostly preventable by changes in diet and physical activity. But its spread has increased 32 percent in California in the past decade, according to state statistics. The disproportionate impact on low-income communities and people of color may partly explain why it gets short shrift, experts say.

“There’s a general belief that it’s slothful, lazy people making bad choices,” said Dean Schillinger, professor of medicine at UC San Francisco, a leading expert on diabetes and prevention and chief of the state’s diabetes control program from 2008 through 2013. “But if you have to choose between buying a fast-food meal for your family of five for $15 or going to Whole Foods and spending $80 on health food, it’s very rational what people are doing.”

Add to those economics the marketing of beverages and snack foods to children, especially through targeted advertising in low-income communities, and you have a natural intersection for the disease, he said.

Diabetes is also increasing among white people, Schillinger noted, just not as quickly. Sedentary lifestyles, fat-rich diets and time spent in front of screens large and small cut across all communities.

Another contributor is a health care industry that has been primarily focused on treatment instead of prevention, said Monning: “Prevention, including diabetes prevention, is not profit-generating.”

He and a handful of other state legislators have been trying to pass measures to blunt the growth of diabetes for years, focusing on the role of sugar-sweetened beverages because they are the leading cause of increased calories in children. The lawmakers’ targets include not just sodas but also other sugary drinks camouflaged as more healthful: sports drinks, juices and enriched waters.

Monning tried this year to require labels on certain drinks to state that “drinking beverages with added sugar contributes to obesity, diabetes and tooth decay.” Other efforts have involved a statewide tax on such drinks, but that requires a two-thirds vote of the Legislature and has been a hard sell.

The beverage industry argues that the causes of diabetes are complex, involving much more than soda, and that the best way to build strong, healthy communities is to work together to “help people balance their calories and improve their diets,” said Lauren Kane, a spokeswoman for the American Beverage Association.

The group says taxes don’t work and labels are misleading.

“America’s beverage companies are already helping people cut their sugar intake from beverages through our collective efforts to reduce portion sizes and introduce smaller, more convenient packages with less sugar,” Kane said.

But Monning blames the industry for pushing hard enough—and spreading enough money around Sacramento—to scare off the “yes” votes needed to pass preventive measures. The beverage group has spent $282,000 on lobbying in California so far this year, according to its required reports to the state.

There has been a slight decline nationally in the consumption of soda, studies show, although the void may be at least partly filled with other sweet drinks. Experts credit local measures to tax sweetened beverages and require warning labels on billboards that advertise them, among other moves.

Such taxes have been imposed in Berkeley, San Francisco and Oakland. Others, including Richmond, have tried and failed to pass them. San Francisco approved a requirement two years ago that certain beverage ads be labeled, but the beverage industry sued to block the measure in a case that is ongoing.

More local taxes and labeling requirements could prompt state lawmakers into action eventually, as plastic-bag bans throughout the state did, said Monning. Once a tipping-point number of cities outlawed the bags, it became easier for the Legislature to adopt a statewide policy.

Schillinger said he has seen first-hand that prevention efforts can stem, or even reverse, an epidemic tide. When he started his medical career, at the height of the AIDS epidemic, half his patients were dying from HIV infection, he recalls. Within 15 years that epidemic was pushed back by a combination of grassroots activity, well-funded public health work and scientific research, he said.

“At that time, one out of 15 to 20 of my patients had diabetes,” he said. “Flash forward and I have no patients with AIDS who are dying. Our AIDS ward is empty. But instead we have the diabetes epidemic,” and half his patients have the disease.

Schillinger lauds community awareness efforts, like the videos posted by Youth Speaks as part of its diabetes-prevention program. Even armed with statistics and an M.D. degree, Schillinger said, he has participated in too many disappointing policy discussions with lawmakers about diabetes.

“There has to be a different way to talk about this,” he said, “and it has to come from different people.”