Ann L. Albright, PhD, RDN, is Director of the Division of Diabetes Translation at the Centers for Disease Control and Prevention (CDC) in Atlanta, Ga. Dr. Albright led the development of the National Diabetes Prevention Program (National DPP), has served as CDC’s lead media spokesperson and designee for congressional briefings on diabetes, and has coordinated with the Centers for Medicare and Medicaid Services to establish and implement Medicare coverage for the National DPP lifestyle intervention initiative. She is the past president of Health Care and Education for the American Diabetes Association.
Dr. Albright met with KET in July 2019 to discuss the rising rates of diabetes in Kentucky and the U.S. as part of the upcoming documentary “Undiagnosed: The Diabetes Epidemic” funded in part by Foundation for a Healthy Kentucky. An edited transcript of her interview is presented below.
1. Describe the current landscape for us – where are we right now in the U.S. with respect to diabetes and prediabetes? What is the scope of the problem?
Diabetes is a major public health problem for our nation. There are over 30 million people who have diabetes, and another 84 million that have a condition called prediabetes, which means your blood sugar is higher than normal, but not high enough yet to receive a diagnosis of diabetes.
And when you think about the burden of diabetes, it’s not just the number, but it’s the things that diabetes brings with it. Diabetes is a leading cause of amputation, blindness, and kidney failure. It’s a huge contributor to heart attack and stroke. We have an ever-increasing number of health conditions that diabetes is linked to, things people really weren’t aware of in the past. Certain forms of cancer, dementia, hearing loss, bone loss – the list continues to grow.
Diabetes is also a very costly condition. It’s costing our country over $327 billion, and it’s costly in terms of human suffering with all of these complications. So it’s time that our nation really focuses on diabetes as the major national public health problem that it is.
2. Can you explain the difference between type 1 and type 2 diabetes?
There are a few forms of diabetes, and the two major ones are type 1 and type 2. Type 1 diabetes is an autoimmune disease in which the body has essentially destroyed the cells that make insulin
, so it’s not really related to lifestyle. It could be related to things in the environment. We don’t know all the causes of it, what starts that autoimmune cascade.
Type 2 diabetes is the most common form of diabetes, and it’s really a combination of your genetics and lifestyle. There’s a double duty – you do have a genetic contribution, but it also has to do with the environment you’re living in.
There’s a saying that we often use these days: your zip code is more important than your genetic code as far as type 2 diabetes and how well you’re able to manage it. It’s that combination of what you’re able to do and what your lifestyle habits are, but those are heavily impacted by where you live, who surrounds you, what options you have, and you’re ability to gain access to things that will help you live healthfully.
3. Diabetes has been gradually increasing, but in recent decades it’s increased quite significantly. What has caused that faster increase?
The prevalence of diabetes – the total number of people who have diabetes – and the incidence of diabetes – the new cases of the disease – have been increasing significantly over the last two decades in particular. And there’s no single reason one can point to. The numbers have been impacted by the diagnostic criteria that has been used, and that has been adjusted, because it’s been determined that people are actually suffering from the consequences of diabetes at lower blood sugars than we used to think.
There’s also investigations and research going on now that’s looking into some environmental contributors to diabetes. Whether they are environmental contaminants or other things, that we have yet to truly understand
4. One of the things that is striking about the current level of diabetes cases in the U.S. is how many people are walking around unaware that they have diabetes or prediabetes. It’s a significant number. Why is that? Why are there so many people walking around undiagnosed?
Of the estimated 30 million people who have diabetes, about a quarter of them don’t know they have it. Of the 84 million who have prediabetes, only one in 10 people know they have it. So 90 percent of the people with prediabetes are undiagnosed.
There are a number of factors that contribute to the reasons why people don’t know they have these conditions. First and foremost is awareness. We are really just beginning a conversation about prediabetes in our nation. Prediabetes is a condition that usually precedes the development of type 2 diabetes. It’s the warning sign, it’s letting people know that they are at risk. And by the way, they’re at risk not only for type 2 diabetes, but for heart attack and stroke. We need to be talking more about diabetes and prediabetes in this country, we need to be paying more attention to it. That will lead people to become more engaged with their health care providers about getting tested.
Many people are likely being tested, but they’re unaware that they are. So, the clinician community needs to be having that conversation with their patients. If you’re a clinician and are running that test for diabetes and prediabetes, tell your patient, talk to them about it. Help them to understand what those numbers mean and that there are things the patient can do to both prevent and delay type 2 diabetes. And tell them that there are absolutely many things they can do to help manage diabetes if they do get that diagnosis.
5. Let’s talk about screenings. What can we do to increase screening rates when so many people are walking around undiagnosed?
There are a few ways you can be screened. You can be screened by going through what we call a risk test. It’s a set of questions that help identify your risk factors. It’s questions like, how old are you? Do you have a family history of diabetes? Are you overweight or obese? Are you a member of a higher-risk ethnic population?
So, you go through this list of questions and there are points attached to each answer. They just help weigh the risk factors for you, and it’s a really great first step. We encourage everybody to get online and take that risk test.
We have a website, doihavediabetes.org that’s a great place to go. Organizations can use that tool at community events or churches. The tests can be freely given to people and help people know where they stand.
This is not a diagnostic test (for diabetes), but it’s a really great first step. At CDC, we encourage a two-step approach where you do something like this risk test, and then you go and get a subsequent blood test to confirm whether or not you really have prediabetes or diabetes.
The really important thing is that when people are screened and then subsequently diagnosed
, they really need to get connected to the services that are going to help them. Because strictly screening people and sending them on their way, that’s really not an effective way to help people. There may be good intentions, but it’s really not going to help somebody take action and get help and services that they need.
5. Can you talk more about the need for a national conversation on diabetes and why it’s so important?
There are a lot of exciting developments that are happening in diabetes research, but there’s also a tremendous burden placed on our country by diabetes. It’s a proverbial good news, bad news story.
The rates of diabetes and prediabetes have continued to climb during the last two decades. We do have some encouraging recent data indicating the number is beginning to plateau and we’re seeing a decline in new cases. But those encouraging results can turn right around and become discouraging again if we don’t really focus on preventing or delaying type 2 diabetes and really implementing good care for those that have the disease.
In order to do that, we need to have a much more visible, vocal, fervent conversation about diabetes in our country. It needs to be dealt with and talked about like we do for other very serious health conditions in our country that are now top of mind, like opioids and HIV.
There are actually some parallels between diabetes and HIV and opioids. There’s a lot of stigma around particularly type 2 diabetes, just as there is around HIV and opioids. There are also some medical connections. And the fact that there are people who have AIDS and take certain medications, those may result in the development of, or actually a form of, diabetes. And then certainly with opioids, there may be people who have diabetes who had been prescribed opioids for a diabetes related issue. While it’s not a first- or second-line medication, it does happen.
6. Let’s talk about prediabetes. Why is it so important to define that as a condition and to address it?
Prediabetes is a condition in which your blood sugar is higher than normal, but not high enough yet to receive a diagnosis of type 2 diabetes. And the reason it’s important to talk about prediabetes is that it’s a huge warning sign. If you knew that a building you were in was going to catch fire or that an earthquake was going to happen, wouldn’t you take action? Wouldn’t you leave the building and go to a safer place?
We should look at prediabetes that way, that it’s a warning sign. It’s helping people know that they are at high risk for developing type 2 diabetes. And the good news is that you can now intervene in that stage in this trajectory, because it runs along a continuum. You can go from really normal blood glucose, into this prediabetes stage, and then into this type 2 diabetes stage. And we need to intervene all along that continuum, we should be doing things.
When women are carrying babies, we need to make sure that they’re healthy during that time, because there are things that can actually be programmed during that pregnancy process that can contribute to obesity and the development of type 2 diabetes. And then there are things that should be done for youth during school age and early childhood that can help them set up for good lifestyle habits and a healthy life. And then as you age, there are things that we need to be sure are happening and are supported so that people can adopt healthy lifestyles – and most importantly, sustain them.
7. Tell us about the National Diabetes Prevention Program, which is where you’d like to get people with prediabetes connected to programs. How does it work and why it is so effective?
The National Diabetes Prevention Program – we call it the National DPP for short – is really exciting. There is finally an opportunity for us to be implementing a proven lifestyle program, a lifestyle intervention that has been shown to prevent or delay type 2 diabetes for those at high risk. In fact, in a research trial, there were 58% of the people who went through the program that prevented or delayed type 2 diabetes initially. And even after 15 years, still there were a significant number of people, 27% of them still were able to prevent or delay diabetes after all those years. So that is really exciting news.
That lifestyle intervention is now being implemented nationwide. We are working with all kinds of partners all over the country to be able to help that program be accessible to people, and help it be delivered in places and at times where they can access it.
And, this program is a year-long program. It’s a structured lifestyle program where people initially meet once a week for the first six months, and then once a month or so for the remaining six months.
During that hour-long session, you actually get access to your own lifestyle coach, and you get access to others who are in similar shoes. You can share ideas and you can help problem-solve with each other. And your coach is there to give you guidance and really to listen to you and hear what you’re challenged by. Together, you’re able to find solutions and offer support, and that really is key to any kind of change that requires us to make changes in our own behavior.
For example, you’ll learn strategies for troubleshooting and problem solving when you go out to eat. What do you do during the holidays? What do you do when you are really hungry and you’re struggling with that? How do you find places to be physically active when you may not live in a neighborhood that’s really supportive of that? The National DPP is really helping you make those real life choices for your circumstances; it’s not some piece of paper that isn’t relevant to you. The program can be delivered in multiple languages. You work with the coach and others to make it really personal for you, and that really allows for flexibility, which you need to have a successful program.
8. You don’t have to get too clinical, but can you explain why exercise helps prevent type 2 diabetes? And why is it that eating certain foods versus other foods helps?
When you’re thinking about food and physical activity, it’s an issue of certain foods and lack of exercise contributing to excess weight. When the body is carrying excess weight, it means that those cells that your insulin – that hormone that helps you take sugar into your cells and use it for fuel – doesn’t work as well. So you develop what we refer to as insulin resistance. Being more physically active helps reduce that insulin resistance, it makes sure your cells are willing to take in that sugar, that glucose, and use it for fuel.
As far as food, you may have to think a little bit more about how its prepared. Participating in the National Diabetes Prevention Program helps you learn how to do that. Think of the word whole when you’re thinking of the foods you’re choosing. You want to drink a lot of water. You can still certainly consume fats; fortunately, there are healthy fats. You want to think about things like olive oil, nuts, whole grains, and lean cuts of meat. Those kinds of foods have higher value, they give you more bang for your buck.
When you’re thinking about high fat, high sugar foods, those are foods that I would refer to as sometime foods. Not all the time foods. When you’re thinking about those whole grains, fresh fruits and vegetables, water, and lean cuts of protein, those are always foods. It’s good to think about food in that way where you don’t feel like you’re being deprived of food. Food’s a very personal thing. We celebrate with it. We unfortunately console ourselves and deal with stress through food. So if you’re going to do that, you really need to learn other strategies for coping. The foods you choose can make a big difference.
9. Let’s talk a little bit about disparities in terms of type 2 diabetes. Where do you see the most disparities, and what’s being done to address that?
There are disparities in diabetes as there are in many health conditions. There are certain populations that are harder hit by the disease than others. I think it’s important to know that diabetes knows no bounds. It will impact the young and old. It impacts all racial and ethnic groups, all socioeconomic backgrounds. It touches everybody.
It does touch some people harder, though, and some populations are more affected – those are high-risk ethnic groups. African Americans, Hispanics/Latinos, American Indians, Alaskan Natives, and some Asian and Pacific Island populations. It does tend to impact older adults, we see a much higher number of people developing diabetes as they age.
It also hits harder those who have lower socioeconomic standing because, again, of the environments in which they’re living. Type 2 diabetes is that combination of genetics and lifestyle. We will see higher diabetes cases in harder-hit neighborhoods, where there are more difficulties, higher crime, lower education, higher poverty rates. Those all impact your lifestyle.
That’s why we are working to prevent or delay diabetes as a nation using this National Diabetes Prevention Program. We need to be working on improving the environments where people are living. Working to make them healthier and more economically viable. Because that’s going to have an impact on not just diabetes, but the environmental changes impact really every ill that is facing us – it doesn’t matter which health condition it is.
10. In Kentucky, many people have a mindset of, “Well diabetes runs in my family, it’s just part of life….“ What would you say to them?
It’s not uncommon in particular locations or in particular situations for people to feel really fatalistic about diabetes, because everybody in their family has it. Their neighbors have it, they are surrounded by it. So they just sort of assume it’s going to happen to them and there’s nothing they can do.
Fortunately, there is something they can do. And I hope that message helps give them hope that diabetes doesn’t necessarily have to be your outcome. You don’t necessarily have to develop diabetes, even if it seems like everybody around you does.
Some of the things you can do are smaller goals. It can be looking for any opportunities that you have to be physically active, even in your own home. If you love music, put music on, whatever it is that you like, and move. You can bring your friends together, go for walks together in places where you feel it’s safe. Communities can open locations, community centers or schools, that help people have safe places to walk.
Another small step is to begin talking in your family about diabetes. Talk about ways to use the family and community to help problem solve. People are incredibly creative in things that they can do.
It’s important to acknowledge that there is a stigma around diabetes, particularly type 2 diabetes. Many times, people are fearful to admit that they have it because people look at them as if it’s their fault, and that they were lazy, and that they brought it on themselves. And that is such an unfortunate and really useless conversation because it doesn’t lead to any solutions. It just makes people feel guilty and want to hide their diabetes. That’s not how things happen. Gandhi said we need to shine a light to solve a problem.
So we need to shine a light on diabetes. We need to help people feel empowered to talk about their diabetes, to not be ashamed. That’s what it’s going to take to help us speak about it and get it out in the open so that we can be much better about coming up with those solutions in our homes and our communities. It is incumbent upon us, and the health of the nation is depending on that.