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Health reform should include diabetes 'war'

It would be entirely fitting for Congress to rekindle the "war on cancer" in response to the death of Sen. Edward Kennedy, D-Mass., but another disease worthy of a war is diabetes.

Cancer kills more people each year -- 560,000, according to the Centers for Disease Control and Prevention, compared with 233,600 for diabetes and its complications.

But the CDC estimates that the diabetes figures are hugely underreported and that the actual numbers may be 65 percent higher, or 386,000.

Kennedy's death from glioblastoma, an aggressive brain cancer, is one reason for a renewed attack on cancer.

But, as Gina Kolata pointed out in an illuminating article in The New York Times, Kennedy called for a cancer war months before President Richard Nixon declared it in his 1971 State of the Union message.

Kennedy advocated a larger research budget than Nixon's and enhanced status for the National Cancer Institute -- ideas Nixon agreed to support as long as Kennedy's name was not on the bill.

Kennedy agreed, and Nixon signed a cancer bill in December 1971. Cancer has received one of the largest budgets at the National Institutes of Health ever since, but clearly it is still not conquered.

The reason for a war on diabetes is that, like some cancers, Type 2 diabetes -- the most prevalent type -- is heavily a "lifestyle disease" resulting from overeating and lack of activity. Therefore, it's preventable.

(Type 1, or juvenile diabetes, occurs when the body's own immune system attacks the pancreatic cells that produce insulin, the hormone that processes glucose.)

Diabetes can result in ghastly consequences for its 24 million victims, including heart disease, stroke, blindness, kidney failure, amputations and nervous system disease, and it is hugely expensive to the economy.

The CDC estimated the national cost of diabetes in 2007 at $174 billion, including $116 billion in medical expenditures and $58 billion in lost productivity.

According to a 2007 study by the policy research firm Mathematica, the federal government spent nearly $80 billion of that, 12 percent of all federal health spending.

Yet, Mathematica found, 19 different federal agencies spent only $3.9 billion on disease-prevention or health-promotion activities with some impact on diabetes.

If a "war on diabetes" were declared, it ought to begin with a war on obesity, the epidemic most responsible for rising incidence of Type 2 diabetes among both adults and, increasingly, children.

In 1980, the CDC estimated that 47 percent of U.S. adults were overweight. In 2006, it was an astounding 66 percent, and 34 percent were obese -- 72 million people.

Insurance companies and employers have developed incentives for workers to lose weight and become fit, such as insurance-premium reductions or paid-for gym memberships, but fighting obesity ought to be a major focus of health care reform.

David Snow, CEO of the pharmaceutical distributor Medco, recommends that the government run TV ads to promote healthy lifestyles akin to its fried-egg "your brain on drugs" ads or Smokey Bear anti-forest-fire spots.

I'd go further--pushing videos in school health classes showing diabetes amputees and kidney-disease victims the way drivers' ed classes used to scare kids with car-wreck films.

Conservatives will surely scream "nanny state" at such moves, but the fact is, obesity costs--as much as 27 percent of recent increases in national health spending, according to health analyst Kenneth Thorpe.

Beyond combating obesity, there's a need for better diabetes screening in government health programs. Medicaid and Medicare ought to adopt the kind of intensive disease-management techniques that many insurance plans employ.

Many plans hire contractors employing nurses to routinely check on patients' blood sugar levels and monitor complications--and pay doctors to prevent complications, not just treat them.

There's increasingly a role for technology. The computer chip maker Intel has deployed a series of home monitoring and communications devices, but it is stymied by Food and Drug Administration regulations from going as far as it could.

In Asia, for instance, cell phones are equipped with glucose-testing kits that transmit data to a monitor. Here, the FDA would have to re-approve such a device every time its technology was updated.

How much of the government's $80 billion annual diabetes outlay -- expected to triple by 2020 -- could be saved by intensive prevention and management? It's a disputed point.

The Congressional Budget Office estimates costs and savings only within a 10-year "window," whereas chronic-disease management probably would show results over a longer period.

A new study in the journal Health Affairs estimated that what amounts to a "war" on diabetes, costing $800 million a year, would merely pay for itself over 25 years, not cut the actual costs to the government.

But such a war surely would prevent many strokes, heart attacks, leg amputations and kidney failures. It's hard to believe that wouldn't save money, too.
