The incidence of Type
2 diabetes has increased to 9.4% of the adult population, increasing by 1.5
million from 2016 to 2017. The Center for Disease Control and Prevention
estimates that 23.1 million U.S. adults have been diagnosed with Type 2
diabetes, 7.3 million are diabetic but undiagnosed and 84.1 million have
pre-diabetes and are at risk. Costs for treatment of those who are diagnosed
increased to $322 billion in 2015, up 31% from $245 billion in 2013 and are
expected to double in the next five years .
officials attribute the increased incidence of Type 2 diabetes to many factors:
heightened incidence of obesity and hypertension, decreased physical activity
and changes in eating habits among them. Many with prediabetes are unaware they’re
at risk; and among these, many are unwilling or unable to make lifestyle
changes that might slow its progression to diagnosed Type 2 diabetes and its
Reduction of the
prevalence of Type 2 diabetes and its costs requires changes in eating habits
and lifestyle changes to slow its severity for those already diagnosed and
reduce its progression among persons with pre-diabetes. For those diagnosed and
in treatment, medication and changes in eating habits have been the primary
focus; for those with prediabetics, improvement in food choices and lifestyle
changes have been encouraged, but public confusion about healthy diets and
inability/unwillingness to make lifestyle changes have been problematic.
Policymakers and public
health officials should take two immediate steps to address the problem: (1)
The U.S. Dietary Guidelines should be updated to include food options
(nutrition therapies) to address the heterogeneity of the prediabetic and Type
2 populations and provide evidence-based directives for consumers and their
caregivers. (2) A public education campaign should be developed to educate
consumers about the Dietary Guidelines and nutrition therapies to nullify
nutritional advice that is misleading, contradictory and confusing.
America’s most pervasive chronic health condition, impacting 30.3 million adults.
Type 2 diabetes accounted for 95% of diabetes-related illnesses and cost the
nation more than $350 billion to treat last year. More problematically, 84
million adults and adolescents exhibit common risk factors for Type 2 diabetes,
such as obesity and hypertension, although 90% are unaware .
have shown the incidence of Type 2 diabetes is 50% higher among African Americans and Hispanics compared to non-Hispanic whites . Clinical studies have shown those with Type 2 diabetes at higher risk of
stroke, blindness, kidney disease and loss of toes, feet or legs . And risk factors associated with Type 2, particularly obesity, are known to
contribute significantly to its increased incidence. Notably, the National
Center for Health Statistics’ 2017 National Health Interview Survey found 31.5%
of U.S. adults are obese -- up from 19.4% in 1997. Continued increases are
forecast across all age, sex and ethnic cohorts .
with Type 2 diabetes are significant and increasing: direct medical costs for Type
2 diabetes in adults, depending on their sex and age, range from $54,700 to
$130,800 per individual over the course of his or her lifetime-2.3 times costs
for non-diabetics . In 2015, total spending
for diabetes, including direct costs and lost productivity, was $322 billion,
up from $174 billion in 2007 . And forecasts
are that costs associated with Type 2 diabetes will ramp up because of increased
prevalence and growing costs for diabetes drugs, among other factors .
and policymakers have deduced that the increased prevalence and cost associated
with Type 2 diabetes is attributable to five major factors:
According to the U.S. Department of Labor Bureau of Labor Statistics,
employment in America has shifted from farm to factory to desks at home or in
congregate workplaces, and from rural to urban and suburban settings.
Researchers have associated this change in work with decreased physical
activity and increased adoption of sedentary lifestyles . A 2015 study of workers who spend 8-12 hours at desk jobs found
they had a 91% higher likelihood of developing Type 2 diabetes .
in American demographics: Pew Research
Center’s “10 Demographic Trends that are Shaping the U.S. and the World” offers
a compelling summary of demographic changes over the past 50 years: America is
becoming more ethnically diverse; families and household composition are
shifting from two parents and children to other living arrangements. And we’re
getting older . That’s led to changes in how
individuals spend their time and money, what and where they eat and how they
define healthiness. Notably, for three decades, more was spent on fast foods
and less on healthier food options, contributing to higher incidence of
obesity, heart disease and diabetes.
system bias toward medication: The $3.3 trillion dollar U.S. health
system is highly specialized: payments for primary and preventive health
services are less than 8% of total funding and have been flat in recent years . Clinicians are paid for the volume of patients
they engage. As a result, prescribing drugs to treat medical problems is seen
as a safe, efficient way to treat medical problems. For Type 2 diabetics,
prescription use has become a mainstay of treatment: 76.2% of office visits
result in a prescription .
about healthy food choices that are problematic to people with diabetes and
pre-diabetes: Most Americans are
confused about what constitutes a healthy food choice, according to the
International Food Information Council Foundation's annual Food and Health survey . Eight in 10 survey respondents said they found
conflicting information about what foods to eat and what foods to avoid and
half said the conflicting information confused them. Most were unable to
discriminate between saturated and unsaturated fats and unaware of distinctions
between genetically modified and organic foods .
Food packaging contributes to the confusion: “multi-grain” is confused
with “whole grain,” an especially important distinction for
prediabetic/diabetic sufferers who have compromised insulin levels and there’s widespread
misunderstanding about the role carbohydrates play in raising blood sugar .
prioritization: For policymakers,
tackling Type 2 diabetes and the growing incidence of pre-diabetes is
problematic. Conditions like heart disease or cancer impact large numbers and
are associated with specialized technologies, facilities and clinicians.
Improvements in the diagnosis and treatment in these diseases has been steady
and public awareness is strong. Public health issues like drug abuse garner
media attention, prompting policymaker action. But policymaking around Type 2
diabetes is more challenging. Root causes are associated with lifestyle
factors: obesity is a major risk factor .
And obesity is complicated by socio-demographics correlating higher levels with
lower income and certain disadvantaged groups.
For policymakers, addressing Type 2 diabetes goes beyond just healthcare and requires
prioritization of nutrition therapy, vigilance about the food supply chain,
pricing policies to make healthier foods more accessible and other actions. And
these require coordination across multiple state and federal agencies and
programs since food production and safety fall under the aegis of the U.S. Department
of Agriculture and the Food and Drug Administration, and treatment falls under
a wide range of payers including Medicare, Medicaid, private insurers and other
sectors of the healthcare system.
Remission of Type 2 Diabetes Achievable?
progression of Type 2 diabetes is necessary to reduce long-term costs
associated with its treatment. Evidence also shows that Type 2 diabetes can be
reversed with proper nutrition therapy and exercise .
Studies have shown
that a 1% reduction in HbA1c, a key indicator of Type 2 diabetes, can be
achieved through proper dieting. It also results in lower risks for heart
disease, renal failure and blindness, saving $1,700 per year in medication
costs . In a one-year paired comparison
study released in February, 2018, Type 2 diabetics who followed a low
carbohydrate diet had “lower HbA1c, weight and medicine use” . If 20% of the 30 million U.S. T2D sufferers made
this dietary change resulting in a HbA1c reduction of 1%, savings to the U.S. healthcare
system would be at least $10.2 billion annually. If the 84 million prediabetic
Americans followed a similar regimen, cost savings would be even more.
therapies targeted to specific patient cohorts of inidividuals with Type 2
diabetes and prediabetes are underdeveloped by the American Diabetic Association.
While the ADA’s Guidelines are useful to individuals in good health, they inadequately
differentiate between key patient cohorts for whom nutrition therapies produce
significant clinical benefit . A notable
example is the ADA’s failure to consider studies that have shown low carbohydrate
diets to be safe and effective in managing glycemic control and weight among prediabetics.
Instead, the ADA’s grading scheme rates them lower than plant-based options
though the evidence is otherwise (See Appendix).
properly administered, can play a larger role in Type 2 prevention, treatment
and reversal strategies. Studies show a low carbohydrate diet offers
therapeutic benefits to many people with diabetes as well as lowers lifetime
health costs . Regrettably, medications have been the
default therapeutic strategy for most of those with diabetes when evidence
shows other options to be more effective for many.
We Stand Today
Today, 84% of
total U.S. health costs are attributable to chronic diseases: Type 2 diabetes
is at the top of the list. Currently, the public policy framework for
addressing the progression of Type 2 diabetes centers on three co-dependent
care diagnosis and coordination: Increased access to primary care and
preventive health services in local communities, especially in under-served and
low-income populations has been associated with lower incidence of Type 2
diabetes . Access to primary care services
by physicians, nurses and allied health professionals is important to
recognizing incidence of Type 2 diabetes and risks among predisposition by persons
with pre-diabetes. But only one in three adults has a regular check-up, and
large numbers in the population, especially younger adults, are not inclined to
maintain a routine primary care regimen .
The U.S. Dietary Guidelines are codified in the 2015-2020 Dietary Guidelines for Americans
produced by the U.S. Department of Agriculture (USDA) and Department of Health
and Human Services (HHS) . The U.S.
Preventive Services Task Force references ‘weight control’ sparingly in only two
of its 94 recommendations . Both agencies
contribute to the public’s understanding of risks and conditions that lend themselves
to Type 2 diabetes control, but neither incorporates the expanding body of
evidence about dietary correlation to diabetes prevention. Both offer a credible
perspective, but each fails to provide direction explicit to those most at risk
for Type 2 diabetes.
Provider organizations, private health insurers, Medicaid and Medicare invest
significant sums in educating consumers about risks for and mitigation of Type
2 diabetes. However, the most trusted source of patient education is the
physician . That’s where issues in educating
patients about diabetes becomes problematic. Physicians have limited time to
educate their patients; most sponsor a website and provide generic materials,
but customized care for Type 2 diabetics is rare.
Progress has been
made in these areas, but results have been disappointing. While the public
maintains healthiness as a goal and believes nutrition and regular exercise
important to being healthy, only one in five exercises regularly and one in
eight eats a healthy diet. And both are vital to arresting the progression of
Type 2 diabetes .
Policymakers must refresh
the nation’s health policies as they relate to the growing prevalence, cost and
impact of Type 2 diabetes. Current efforts in primary care, guideline
development and public education are not slowing the growth of Type 2 diabetes
and its negative impact on the healthiness of our population and awareness of
the risks of diabetes.
steps should be taken by policymakers in tandem with public health officials
U.S. Dietary Guidelines should be updated to include food options that address
the heterogeneity of the prediabetic and Type 2 populations. A
one-size-fits-all approach is scientifically misleading and harmful to the
public education campaign should be developed to educate U.S. consumers about
nutrition therapies that address diverse populations including pre-diabetics
and others and equip them to avoid nutritional advice that is misleading,
contradictory and confusing.
In addition to
these, consideration should also be given to:
of diagnostic screening measures used by primary care clinicians, retail
clinics and other primary care venues to diagnose pre-diabetes and Type 2 diabetes.
Consideration should also be given to increased nutrition therapy CME/CNE
educational requisites across all primary care professions.
in medical education to emphasize nutrition therapies
of explicit nutrition therapy outcomes in alternative payment programs
including Medicare Shared Savings Program (Section 3022 Affordable Care Act) and
of a blue-ribbon commission on nutrition therapy to modernize policies, regulations
and food supply chain considerations.
must be taken to contain and reverse the epidemic of Type 2 diabetes. Its
impact and cost, left unchecked, will undermine the entire healthcare system. More
must be done: the status quo is not working.
Paul Keckley, Ph.D. received funding from Atkins Nutritionals, Inc. to write this article.
Appendix A Source (Citation)
American Journal of Clinical
“Brinkworth2: Comparison of
low- and high-carbohydrate
diets for type 2 diabetes
management: a randomized
Randomized trial conducted
over 52 weeks of obese adults:
Group 1: low fat/high carb diet
Group 2: Low carb/high
unsaturated fat/low saturated
Conclusion: ‘While both groups
saw similar weight loss
outcomes, the low carb group
had significant improvement in:
Lipid profile, Blood Glucose
Stability, Reduction in diabetes
and Reviews (2010)
“Enhanced weight loss with
replacements in subjects with
the metabolic syndrome.”
Randomized control trial in
obese patients conducted over
Group 1: High protein diet (1.34
g protein/kg of bodyweight).
Group 2: Normal protein diet
(.8 g protein/kg of bodyweight)
Results: After 12 months of
64.5% of the subjects in the
high-protein diet group vs
34.8% of the subjects in the
conventional diet group no
longer met three or more of the
criteria for having the metabolic
The New England Journal of
Weight Loss with a Low-
or Low-Fat Diet
Randomized cohort study--
assignment of 322 obese adults
assigned to 3 control groups
followed for 2 years:
Low fat- restricted calorie
Low carbohydrate- unrestricted
Low carbohydrate group lost
20% reduction in total
cholesterol to HDL in low carb
group vs 12% in the low-fat diet
“Low carbohydrate diet is an
effective alternative to low fat
diet for weight loss.”
NIH and Johns Hopkins
“Low-Carb, Higher-Fat Diets
Add No Arterial Health Risks to
Obese People Seeking to Lose
Conclusion: “Low carb/ high fat
diets do not result in additional
heart health risks for obese
patients and are a safe and
effective weight loss option.”
Ajala O, English P, Pinkney J.
Systematic review and metaanalysis
of different dietary
approaches to the management
of type 2 diabetes. Am J Clin
Conclusion: ‘Low carbohydrate
diets improve heart health in
individuals with Type 2 diabetes
and should be considered an
overall strategy in the
management of the disease.’
Fields H, et al. Are lowcarbohydrate
diets safe and
effective? Journal of the
Conclusion: ‘Low carbohydrate
diets are safe and effective in
managing glycemic control and
help achieve weight loss goals.’
“Effectiveness and Safety of a
Novel Care Model for the
Management of Type 2
Diabetes at 1 Year”
carbohydrate restriction and
continuous remote care can
safely support adults with T2D
to lower HbA1c, weight and
Keckley P (2018) The Cost and Impact of Type 2 Diabetes: Policy Recommendations
for a Growing Public Health Epidemic. Food Nutr J 3: 185. DOI: