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Testimony on Diabetes by Allen M. Spiegel, M.D., Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, U.S. Department of Health and Human Services

Field Hearing before the Congressional Hispanic Caucus at St. Phillip’s College in San Antonio, Texas
August 9, 2000

I appreciate the opportunity to testify at this Field Hearing of the Congressional Hispanic Caucus. I am here today to convey some of the excitement and hope we at the National Institutes of Health (NIH) feel about our planned and ongoing research to understand, treat and prevent diabetes. As the Director of the NIH Institute with lead responsibility for diabetes research, I know the enormous burden this disease places on the Hispanic community and why it is of particular concern to the people of South Texas. Diabetes is truly a devastating disease that causes great personal and family suffering and tremendous health care costs. It affects an estimated 16 million Americans, who can be stricken by blindness, kidney failure, amputations, heart disease, stroke, severe oral diseases, nerve damage, and other destructive and painful complications of the disease. Type 2 diabetes, the most prevalent form of the disease, is marked by inadequate levels of insulin production, as well as resistance to the action of the hormone insulin. Type 2 diabetes is the form of the disease that strikes Mexican Americans and other Hispanic groups the hardest. In early 1999, the Centers for Disease Control and Prevention (CDC) reported that six percent of Hispanic adults in the United States and Puerto Rico had been diagnosed with diabetes--twice the rate of non-Hispanic Caucasians--while another six percent were estimated to have undiagnosed diabetes. Diabetes is two-to-three times more common in Mexican American adults than in non-Hispanic Caucasians. Working together with all components of the diabetes community, the NIH is committed to combating these grave health disparities through strong and productive research programs and outreach and education efforts.

The many Institutes and Centers of the NIH have a broad research agenda to treat, prevent and cure diabetes and to prevent the damage it causes to the eyes, kidneys, limbs, mouth, and other parts of the body. Throughout the NIH, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) leads and coordinates these efforts with a vigorous research agenda aimed at conquering this devastating disease. For example, our recently completed Strategic Plan to reduce racial and ethnic health disparities includes major goals and initiatives targeted to diabetes and its complications. One of these new initiatives focuses on understanding the metabolic, genetic, sociocultural and other factors that contribute to the racial and ethnic differences in the cause and development of complications resulting from type 2 diabetes. With new knowledge gained from this initiative and other studies, we hope to learn how to tailor therapies and prevention strategies to specific populations, and thus increase their effectiveness. In the upcoming year, the Institute will also launch initiatives relating to the role of cellular damage and growth factors in diabetic complications, prevention of heart disease in diabetes, methods to prevent obesity in minority populations, and genetic studies of diabetic kidney disease. In addition, we plan to begin a new national kidney education program, which will target messages to specific audiences, including Hispanics. Diabetes patients now account for approximately 42 percent of the total number of cases of kidney failure in the U.S., and we must find ways to put a stop to diabetic kidney disease and the tragedy it causes.

Another area of new initiative will be studies aimed at understanding the basis of and stemming the tide of type 2 diabetes in children. The recent rise in incidence of this disease appears to be occurring largely in children from minority groups--in parallel with a similar increase in obesity, which we know is a major risk factor for type 2 diabetes. To address this health problem, the NIDDK sought advice from a group of scientific experts, including a pediatric endocrinologist from San Antonio. Based on the recommendations from this meeting, we subsequently issued a research solicitation, co-sponsored by the National Institute of Child Health and Human Development. We expect that our initiative will bring public and medical attention, along with dedicated scientific talent, to help solve this serious and disturbing children’s health issue.

These examples of new initiatives build upon the extensive NIH portfolio of ongoing basic and clinical research on the causes and natural history of diabetes. The hundreds of diabetes research studies supported by the NIH are paving the way to new insights and treatments to benefit diabetes patients and their families. Advances in understanding the underlying causes of diabetes are a critical first step in determining the factors responsible for the higher rates of diabetes experienced by Mexican Americans and other ethnic and racial minority populations. Much basic research is therefore focused on understanding the cascade of events in cell signaling that are required for insulin to be properly secreted and for it to exert its influence on blood glucose levels. The development of new animal models and technologies for studying hormone action at the molecular level is critical to these efforts.

Another important research area is genetics, where the recently completed decoding of the human genome is accelerating research to find and eliminate the causes of many diseases, including diabetes. With new knowledge about the precise location of genes, we can learn how genes function--how they interact and what processes they control--to cause or prevent diseases such as type 2 diabetes. In collaborative research, an international consortium of scientists is pooling information in order to map genes responsible for type 2 diabetes. Currently, the consortium includes investigators representing 24 patient groups from five countries. At locations in San Antonio--as well as in Starr County, Texas, and in the San Luis Valley in Colorado--the genetic linkage analysis includes a significant number of Mexican American families.

Other investments in the discovery of genes and how they function have led to the identification of at least six separate genetic defects in rare forms of type 2 diabetes. Researchers have recently shown that there are two interacting genes which contribute to the susceptibility to type 2 diabetes in Mexican Americans from Starr County, Texas. The identification of the first of these susceptibility genes will soon be published--an important advance. Collectively, these accomplishments are helping us to solve the genetic puzzle of type 2 diabetes--an extremely complex disease in which multiple genes are thought to play a role. Each new clue to the dynamics of the disease process gives us a tool for developing novel therapies and prevention strategies to stop diabetes in its tracks.

In clinical research, key advances have shown how the control of blood pressure, serum

cholesterol, and other lipids--as well as control of blood glucose--is important in the comprehensive care of patients with diabetes. Research has enabled the development of a second generation of drugs for fighting type 2 diabetes, some with different mechanisms of action that help physicians tailor treatment to the needs of individual patients. With respect to complications, NIH-supported clinical trials clearly demonstrated the critical importance of maintaining close control of blood sugar levels throughout the day. These landmark findings have helped to spur the search for easier and more effective means of blood glucose monitoring and control that patients can use in the real world. Moreover, these findings helped pave the way to the ongoing Diabetes Prevention Program (DPP)--a large multicenter clinical trial of primary prevention strategies for patients at high risk for developing type 2 diabetes. This trial is being conducted at 27 centers across the United States, including one at the University of Texas Health Science Center here in San Antonio. The DPP has now completed patient recruitment, with a total of over 3,800 participants--45 percent of whom are from minority groups. We expect that findings from this clinical trial will advance our understanding of the factors that lead to the development of type 2 diabetes and aid in pinpointing effective prevention strategies for Mexican Americans and other high-risk groups.

Another clinical trial of great significance to type 2 diabetes is the Study of Health Outcomes of Weight-loss (SHOW), which is slated to begin recruitment next Spring. This large, multicenter trial plans to enroll approximately 6,000 patients at 16 locations throughout the United States, including the University of Texas Health Science Center in San Antonio. The SHOW trial will include participants from a range of Hispanic populations, including over 350 Mexican Americans.

Complementing the many basic and clinical diabetes research programs of the NIH are critically important diabetes education and information programs--built on science-based messages. The National Diabetes Education Program (NDEP) is a joint undertaking of the NIH and the CDC, with over 200 public and private partners--including several Hispanic organizations. In accordance with its objectives of improving the treatment and outcomes for people with diabetes in order to reduce illness and death, the NDEP has a national media campaign especially targeted to the Hispanic and Latino community, entitled, "Thunder and Lightening." Launched in 1998, this campaign includes television, radio and print public service ads that were released to over 1,000 Spanish-language media outlets nationwide and in Puerto Rico. October 1999 marked the release of a second edition of the campaign, which includes a new series of television, radio and print ads. The NIH and the CDC developed these campaigns with extensive direction and guidance from a participating Hispanic/Latino Work Group, comprised of representatives from several Hispanic health organizations. An upcoming campaign will be the development of nutrition education messages and materials, to be launched this Fall, targeting Hispanics and Latinos with type 2 diabetes and their families. The goal is to encourage individuals to control their diabetes by making healthy food choices.

To bring the message of the National Diabetes Education Program to the community, we call upon key organizations--such as the National Council of LaRaza, COSMO, and the National Hispanic Council on Aging--to help distribute culturally appropriate diabetes education messages through established community channels. Complementing these education campaigns is the National Diabetes Information Clearinghouse, which provides many fact sheets and pamphlets about diabetes and its management in easy-to-read formats in English and Spanish.

Today, I have shared with you just a few examples of NIH programs aimed at conquering type 2 diabetes and halting its heavy burden for the Mexican American community and other Hispanic groups. I believe that our national research and educational programs--in partnership with the private sector, communities, and voluntary and professional organizations--hold the key to eliminating diabetes. We have many important and promising initiatives under way, to which NIH supported researchers are devoting amazing talents and energy. There are many examples of impressive progress, along with ongoing studies that offer great hope. Nevertheless, we recognize that much more work must be done to combat and ultimately conquer diabetes. I am very grateful to have the opportunity to present this testimony today and am pleased to answer any questions you may have.