you tried to call me morning meeting of the health subcommittee is called to order today we're having a hearing on our collective battle against diabetes the progress we've made so far and the challenges that remain over thirty years ago congress passed the national diabetes research and education act the first significant legislation directed at coordinating and expanding the government's research and prevention efforts related to diabetes while we've made tremendous progress in understanding and treating diabetes it remains a significant public health epidemic it's staggering to realize that over twenty three million americans have some form of diabetes today and the number is growing even more troubling is that fifty seven mil and americans are at serious risk for developing type two diabetes including women with just station of diabetes until recently kids were really diagnosed with anything but type one diabetes and the increasing rate of childhood obesity is changing the face of diabetes though and certainly not for the better as we'll hear today from our esteemed panel of diabetes is a leading cause of heart disease stroke blindness and kidney failure as is often the case diabetes disproportionately affects racial and ethnic minorities american indians have the highest prevalence of diabetes nearly four times those of white americans with hispanics and african americans close behind moreover there's a clear economic cost it's been estimated that over two hundred twenty billion dollars in medical expenses in two thousand and seven can be attributed to diabetes and these are serious problems which need aggressive and innovative action today we're going to hear from two of our government witnesses from the national institutes of diabetes and digestive  kidney disease is located and i h and the centers for disease control both will speak to their agency's role in doing landmark research and surveillance work related to diabetes and how this information has been translated into more effective prevention and treatment strategies including the development of key therapies and technology i should add that and i d d k has recently celebrated its sixtieth anniversary conducting and supporting biomedical research to improve health care across the nation and i d d cayley's a nation's federal commitment in research education and health information dissemination with respect to diabetes and supports investigators who continue to make strides in research towards understanding preventing and treating type one diabetes type two diabetes and just station of diabetes it's for these reasons that the ranking member congressman shimkus and i recently introduced a resolution honoring the end i dk for espoused any work now on our second panel comprised of leaders from the american diabetes a sow's the juvenile diabetes research foundation and the national indian health board will also be able to shed light on the partnerships they have with government and in the community to maximize research translating to improve health outcomes lessons learned from innovative research such as that funded by the special diabetes program have informed our efforts to address the epidemic today and will continue to do so in the future i have to mention my home state and say that innovative exciting and collaborative work on diabetes research is taking place across the country in public private partnerships and i am proud that new jersey's life sciences industry continues to play a strong role in contributing to our ability to address the epidemic today and will do so in the future before i turn it over to mr shimkus she is here i wanted to mention that there were many members who asked for this hearing but the most persistent one was certain colorado ms to get but i know that many members have asked that we have this hearing today also my my native american friends have been asking that we have this for some  yell out now mine were mine works just the republican side doesn't work ourselves about our first term we sat together way up front and they moved us so let me let me just welcome folks here and as as a e we will continue to express concern about spending in the debt because budgetary lade affect our ability to get money to research and development we continue to spend more and more money on nation's economy by the end of this year the highest percentage since just after world war two and that's according to the cvo so when we raise issues about the new health care law when we raise issues about standing and dollars are putting ourselves in a in a bad position to really focus on the things we want to do and set priorities as as interest payments will start consuming that so as as we make those cases we do that with the  best intention and this is a this hearing is a result of a letter that was sent by diana and her colleagues we have sent other letters on the law that we hope will be well received to whether it's t c m s actuary or or of concern our high risk pools which were promised a new health care law which some states can't fully fund and operate or the states have turned it over to the federal government because they're not they're not going to manage it themselves we have no idea what we are going to do and those are promises we made as a nation with the passage of the law and the signing by the president so so we have to figure out how we can make keep our promises so i have a lot more i would want to say but i know time is short now you know back my time and thank the chairman for letting me use his chair  for requesting this hearing with me and i also want to thank mr greene and all the rest of the members of this committee because we all share a collective commitment to addressing the issues of diabetes the two hundred  fifty member congressional diabetes caucus is the largest caucus in congress and we strive hard to keep it that way the reason is because diabetes is the fastest growing epidemic in this country and it affects everybody young and old twenty four million people have diabetes in this country this d seven million people which is a quarter of all american adults have pre diabetes so one of our tasks as well as giving quality care and management to the people who already have one of the various forms of diabetes is to try to get these other people back from the brig and this is something that's difficult because most of those people don't even know that they are pre diabetic have we made progress yes we've made some we know that effective patient self management of an individual's own diabetes is arguably the most crucial point part of an overall care regimen and there's now a substantial body of evidence that diabetes self management training is effective but only if the patient has access to it we also know that medical nutrition therapy can have a significant impact on preventing pre diabetes from becoming full blown diabetes one issue that i've been increasingly concerned about and i've talked to a lot of folks about this is access to technology because as the mother of a sixteen year old with type one diabetes i see the wonderful care at vance's that she has access to but these advances are very very expensive she now has a continuous glucose monitor and the sensors that she puts in  twice a week each cost eighty dollars before insurance so i say that myself and the members of the diabetes caucus how can we make those wonderful advances in care and technology available to every diabetic not just those who are fortunate enough to have parents with good health care coverage we also know that disparities in minority populations are too proud prevalent but we haven't done enough research to figure out how to mitigate the disparities in prevention access and treatment for these populations so we've made progress but when the incidence of diabetes in the u s kid ten used to rise unabated it's clear that diabetes has become as described in this week's lancet a public health humiliation for our nation the diabetes caucus has unwaveringly committed to tackle these challenges that are still unmet and to remove this humiliation we will continue to press forward on all of the priorities including making our hard for our efforts to include certified diabetes educators as medicare providers to classify podiatrists as physicians under medicaid and many many other priorities the caucus is going to host a briefing on july twelfth to address the growing epidemic of preah diabetes so we can start thinking about ways to pull those fifty seven million people back from the brink for pre diabetes to type one diabetes to type two to gestational diabetes and even mounted tertian diabetes this condition comes at us and different forms but the urgent the mandates that we continue to work tirelessly to tackle the  issue it's a health issue and it's also a cost issue because of we don't start putting the research into this issue now it's going to overwhelm our health care system as my two young girls become adults so i want to thank the witnesses on both panels for coming today this testimony really helps us set our course as we move forward the rest of this year and into the next year to set our policy as a caucus but also as a health sub nashville area representative for the national indian health board and say a special welcome to him for coming in today and to all of our witnesses we thank you for attending we thank you for the preparation that you put into the hearings to as you come to us and present serious financial burdens and cost patients in tennessee more than three billion dollars in two thousand and seven i had the pleasure of meeting the goal family from middle tennessee last on each and every day for that with the sixth highest rate of diabetes in the nation this is a very important issue to our state of tennessee according to the j d r f over ten percent of tennessee's population is diabetic in an annual obesity report released monday by the robert wood johnson foundation tennessee was ranked the second most obese state in the country  direct link between but diabetes and obesity exist we all are aware of that and it appears that tennessee is on their way to diabetes epidemic due to the prevalence of this disease the research treatment and prevention efforts are a significant focus for our tennessee medical researchers in fiscal year zero nine and we we thank you granted over seventeen million dollars research in tennessee in the american diabetes association has eight active research grants in the state mostly are focused on type two diabetes vanderbilt university medical centers eschaton diabetes clinic is in the midst of ten clinical trials to develop treatments and learn more about the disease and finally in my district we have two wonderful j d r f chapters they are working actively to support those with type one diabetes in the organization has given more than get this fifty five million dollars to tennessee researchers they are doing a great work so for all of our agencies that are in the room we thank you for the work that you are putting in and these volunteers with associations are doing an incredible job in our state so i join my colleagues in saying this is an area where we want to heighten awareness we want to be more proficient in our education efforts and we hope that we provide the proper support for the researchers who are trying to find a cure or a treatment and  thank you chairman palauan for convening today's hearing the term diabetes describes a host of related health conditions that are familiar to us and the facts are staggering more than twenty million americans have diabetes almost sixty million more at risk for diabetes leading cause of blindness in kidney failure people with diabetes at least twice as likely to die of heart disease or have a stroke and diabetes is a seventh leading cause of death it affects all age groups both sexes in every race and ethnicity however older americans as certain racial and ethnic groups are several times more likely to have diabetes than others that's why i'm glad that we are taking the opportunity to learn about landmark research accomplishments ongoing efforts to translate what we know works into practice and research questions we have yet to answer research has shown genetic causes effective prevention  to diabetes and ways to delay and prevent complications and i see another agencies within the department are working to ensure that our government has a coordinated effort to advance diabetes research and improve the health of those affected by this condition still there is work to be done we must continue our efforts to prevent women with gestational diabetes from developing type two diabetes later in life we're not yet able to prevent type one diabetes nor perfected the link between the continuous monitoring of blood glucose and the administration of insulin the so called artificial pancreas this week two new studies on the drug avandia underscore the need to better understand it better treat type two diabetes underpinning all of this is the importance of a broad public health approach to this disease we need thank you mr chairman the world health organization has found that more than one hundred fifty million people suffer from diabetes and it is estimated that this number will actually double by the year two thousand and twenty five for at least the last twenty years diabetes rights in north america have been increasing substantially with about eighteen point two million americans living with the disease in two thousand and two of those roughly ninety percent have type two diabetes which cost the united states as much as one hundred thirty two billion dollars a year the statistics are stock reminder of the impact the disease has on our nation but also reminded of that some americans can be prevented the majority of patients with type two diabetes are obese the connection being that chronic obesity leads to increased insulin result that can then develop into diabetes obesity and many forms i obesity reassessing the food stamp program so that healthy foods are encouraged ensure an access to local parks and recreational programs and promoting employer wellness programs all of the things that the federal government can and should do to encourage healthy lifestyle we should also ensure that americans with chronic diseases have access to quality health care unfortunately president obama's health care reform bill will make it hard for thirteen could run out well before that the congressional budget office in a report released last week supported this finding when stating that the program's funding will not be sufficient to cover the cost of all applicants chairman ranking member has repeatedly called hearings on the new health care law because it is deeply flawed and certainly can and i think will hurt our country since the day the bill was enacted we have been reminded how this bill fails every day american half an hour or so and next on my list is the gentleman from kentucky mr whitfield and after you will will look over well thank you very much and i certainly want witnesses for being here today we appreciate very much the commitment that you have made to help us find a cure for this disease and to reduce the number of people that unfortunately have it and i also hope that those in the audience are not disillusioned th and all of those who are involved and interested in this issue two months ago i was down in my district and i met with the parents and sixteen agers who all had diabetes and we frequently those of us who are laymen think that what you eat in your weight is a determining factor of whether or not you have diabetes but when you talk to these young teenagers all of them are very thin very energetic all of them have diabetes and then you realize what they go through every single day with the testing that they do the monitoring that they do watching the food the emergency runs the hospitals and the impact is going to have on their entire lives it does bring home very clearly the impact that this disease has and i also want to point out that while the federal government spending a lot of money on research we also have some private companies that are spending a lot of money on research and one that i would like to particularly mention is novo nordisk which happens to be a cunt company  an impact on us i look forward to an update today from our esteemed witnesses on the progress of diabetes research after all despite all the promising discoveries over the past several decades there still is no cure no sure fire way to prevent the development of diabetes especially type one as many of my colleagues know i was a school near your nurse for many years and if there's one disease that you're to bring a student a frequent visitor into the nurse's office at school it's diaby this so i certainly became very familiar with the maintenance of type one diabetes and i had been hopeful that by now we would have something in place but there are many problems in things on the horizon which is exciting to know about what we're going to learn today the sad truth however is my colleagues have indicated is that tilt children don't suffer today just from type one diabetes there is such an increase in now in the amount of number incidence of type two diabetes i know there are definite steps to prevent the onset of type two and we can take it in our communities such as increased physical activity and better nutrition but we need also to be creative in how we get the message out to at risk populations especially minority ones and design programs targeted for those populations i think particularly of programs in my district such as state johns latino health diabetes league that initiative in oxnard california which is tailored educational programming to out at risk communities but they can only do this with the right type of evidence based research being conducted at the institutes institutions represented here today some especially curiosity to learn more about how you're working to equip our local communities with the tools that they need to address diabetes prevention and management i look forward to hearing from our witnesses about the exciting work you're doing now and for how congress can better work with you and help you to cheat our shared goal of finding a cure the subcommittee hearing will reconvene and we'll begin with the gentleman from texas mr burgess well i think the chairman for yielding the hearing this morning focuses on an important public health issue obviously a significant impact on our nation and a crippling effect on our budgets and we've already heard statistics from another number of members this morning so i won't repeat those only to mention that my home state of texas over one and a half million people over the age of eighteen have diabetes and in our state it is the sixth leading cause of death two bills which i would like this committee to consider to move expeditiously and mark up of course we've already heard about h r thirty six sixty eight represented to get reauthorize the special diabetes programs for type one diabetes this program was started back in the ninety's under the guidance of then speaker newt gingrich and he continues as do i to support the innovative work of this program in fact there's been some rather dramatic things that have come out of this program including auto transplantation of beta cells from people who have had a dramatic disruption of the pancreas diabetes affecting over two hundred thousand pregnancies a year over seven percent of the pregnancies in this country and they can have significant impact on both mother and child because they are at significant risk of developing type two diabetes and mothers are almost three times more likely to have a recurrence of just a general diabetes and further future pregnancies as with other diabetes trends the rates of gestational diabetes are higher among women of african american hispanic asian and native american descent r fifty three fifty four creates a research advisory committee headed by the c d c to expand monitoring including coordinating efforts to help mothers avoid contracting type two diabetes so i would urge members of the committee to  legislation it does just so happen that i have a sign up sheet for anyone interested in cosponsoring this bill and mr england i would be happy to take that to the floor to save you the trouble while we hear about the increase of obesity  the united states and is raised the prevalence of diabetes generally we also need to hear about the impact of genetics ethnicity imitate age particularly the case of diabetes and focus our research on watch of the diabetes diabetes cause can be reduced or better lifestyle choices with correlation between obesity and lower income levels and diabetes this committee really stressed being involved in encouraging proper nutritional choices for our population work in the lab and communities like mine which has a prevalence of diabetes is far higher than the national average diabetes is a disease that strikes at every level in every racial and ethnic group in america and while it diabetes putting them at increased risk for developing diabetes and complications therefrom particularly disturbing to me the increase in type two diabetes in children the racial and ethnic differences and prevalence of  diabetes when the twelve percent of non hispanic black more than ten percent of hispanics are unacceptable sixteen point five percent of native americans and alaskan natives have been diagnosed with diabetes compared to six point six  amount native american alaskan native populations must be recognized your presence here is certainly a step in the right direction and given these populations of voice on this issue and ensuring that the diversity that exists on every american health issue is not overlooked or forgotten ewoman from ohio thank you mr chairman and i too appreciate you holding this hearing today this is an incredibly important hearing to have i like so many members of the subcommittee care deeply about diabetes and i am a member of the congressional diabetes caucus and i think very much for her tremendous leadership yesterday a young woman from northeast ohio celina williams came into my office celina is a fifteen year old and was diagnosed two years ago with type two diabetes as you can imagine as some of you in this room have experienced personally this was an incredibly scary time for selena and her parents and she was very lucky to be able to participate in the treatment program at rainbow babies and children's hospital which is home to a center for excellence for childhood diabetes activity and nutrition and through rainbow babies selena and her family joined a program called the today program which stands for treatment options for type two diabetes and adolescents and use the today programs goal is to study the best ways to treat type two diabetes in children and in the today program or her family learned the basic skills that she would need as a diabetic tester blood on the whole meter give insulin shots and manage low blood sugars and she also learned through home visit with a certified diabetes nurse how to make lifestyle changes to help her in her entire family be healthier such as how to read food labels manage portions and stay active and through the today program selena has improved her health and she recently did something that she said she never thought she would do she tried out for the freshman basketball team and i'm proud to report that she made it sadly there are millions of children like selena but not all children have the same treatment opportunities or educational proof programs that celina has had but all of those children have great potential and the fact that they don't have that opportunity is heartbreaking so i look forward to hearing about the progress that's been made since the in the battle against diabetes and about the work that still needs to be done and what we can do to help thank you and i yield back thank is the gentleman from illinois thank you mr chairman you know if for no other reason we should as policymakers and taxpayers pay very close attention to diabetes according to a mathematical report by doctors marsha goals are met diaby this cost the government just the government cost eighty billion dollars a year in medical costs that's medicare and medicaid and i'm sure veterans health care etc the c d c is testimony reports that national costs for truth thousand and seven exceeded two hundred and eighteen billion dollars that includes private insurance so if we were to really target diaby this in terms of research in terms of the kinds of public education programs that congresswoman sought and talked about and in controlling this disease we would also be able to save billions of dollars and change lives for diaby this is really a very cruel disease that affects twenty three point six million americans it's cruel to young children who have to drop a lot every day monitor  their their sugar and their and their their diet which is a good thing for all children but in the ways that diabetic children have to do it's really difficult and to millions of adults who develop diabetes later in life particularly for type due to where there really are lifestyle kinds of changes that can be that can be made we we need to invest in public health programs and  for all the rest of diabetes type one and also type two we need to invest in research so i i want to thank congresswoman de gette who has been a champion for her throughout her career here and even earlier on addressing this important disease important in so many ways and and a disease that we can in so many ways affectively address so let's do   colleague's comments of gratitude towards for the leadership of my friend diana de gette on this issue i also want to welcome all the witnesses that we have today we're very much looking forward to hearing your testimony diabetes quite clearly has a sweeping impact on our society and in that vein i'd like to share the story today of a very brave family making a tremendous difference in my district and across the state of wisconsin the whitman's are just like many other american families they love the outdoors they love to take road trips on weekends and they would do anything for their children yet this family has really been ravaged by diabetes grandpa rick has type two diabetes and just had to have his foot abby tate recently their daughter stella just four years old has type one diabetes and has to have her finger pricked dozens of times each day to make sure that her blood sugar level is it safe levels this disease infiltrates every waking moment of their lives you know the whitman's discovered that stella was sick on a family trip to the upper peninsula of michigan after a midnight ambulance ride in a mission to a pediatric i c u since that day they really could have sat back and bemoaned their fate but instead they really thrown themselves into helping stella and the many children like her across the country by championing the juvenile diabetes research foundation of western wisconsin they also carry the torch of another wisconsin hero jesse blogger jesse traveled extensively in his young life educating others about diabetes he even testified before a panel here in congress in support of stem cell research jesse died due to complications of given all diabetes in february of this year at age thirteen but his legacy clearly lives on in my home town at the university of wisconsin the progress towards better treatment is real and f d a approved clinical trial is currently under way for the use of adult stem cells in the treatment of type one diabetes the study is co sponsored jointly by  therapeutics and the juvenile diabetes research foundation researchers are specifically targeting newly diagnosed type one diabetes patients who still have some functioning beta cells left and infusion of targeted st cell therapy could stop the immune destruction and preserve individuals remaining ability to make insulin perhaps the most exciting news for both of the whitman's and researchers in the district that i represent is the passage of the comprehensive health care reform legislation earlier this year this year the bill bans insurers from citing preexisting conditions as a reason to refuse to insure children in america and to ensure that a child like stella will never be without health care coverage and this year that piece of legislation invests one hundred twenty six million dollars through the new prevention and public health fund to help create the necessary infrastructure to prevent detect and manage chronic diseases like diabetes so clearly much work remains to be done so as we work to implement this legislation we must remember the toll that diabetes takes on our families and on our health care system but we must also work to improve and expand existing federal programs that are making a difference today and i'm glad that our witnesses are here to help inform that process thank you mr chairman and thank you again to our witnesses thank you and i think that concludes our members opening statements will now move to our witnesses let me introduce and will first welcome you both and introduce the two of you on my left is dr judith fradkin who is director of the division of diabetes and doctrine ology and metabolic diseases at the national institute of diabetes and digestive the kidney disease is at the national institutes of health fradkin did i pronounce that properly ok and then is in albright who is director of the division of diabetes translation of the centers for disease control and prevention and thank you both for being here i think you know the drill five minute speech is that if you want to submit additional written comments you can and i'll start with dr albright with members of the subcommittee thank you for the opportunity to participate in the hearing i am dr anne albright i'm the director of the diabetes division at c d c i'm trained as an exercise scientist a nutritionist but i also live with type one diabetes for forty two years the diabetes division at c d c translates the science of diabetes into practical strategies to control and prevent diabetes in the u s population and i'll be describing some of our work in surveillance to define and monitor diabetes the re factors the prevention of type two diabetes and management of this disease the ability to identify and the magnitude of our problem through ongoing surveillance as a foundation of work c d c developed and maintains the national diabetes surveillance system it's the world's first system for monitoring diabetes it relies on national and state based household telephone and hospital based surveys vital statistics to monitor trends and in the last two years c d c has developed a methodology to estimate levels of diabetes and obesity at the county level providing policymakers and communities with new information to guide programming and resource allocation c d c in collaboration with and has also initiated the largest major surveillance system to quantify and track type one in type two diabetes in those under twenty years of age called search for diabetes in use among other things search shows us allows us to clarify the degree to which type two diabetes is affecting youth of different racial and ethnic backgrounds findings from our national surveillance system document several increases or successes in the public health response to diabetes over the past decade but have also revealed areas of major concern and continuing threats to the public's health rates of blood glucose being out of control amputations and end stage renal disease among adults have declined however considerable variation in disparities in diabetes care and outcomes remain c d c does work to impact and improve outcomes for women with an at risk for just station all diabetes in collaboration with the national association of chronic disease directors and the agency for health care research and quality we have established a five state collaboration to identify catalog and validate routinely collected data about just station all diabetes identify gaps and documenting prevalence and determine implications for care our greatest concern though is the continued increase in the rate of new cases of diabetes this is a dent in virtually all segments of society this continued increase in the rate of development of new cases and and so unfortunately negating many of the successes that clinical and public health efforts have achieved in reducing the rates of complications the continued increase in diabetes  incidence calls for a comprehensive implementation of a diabetes prevention strategy so c d c is engaged in a risk reduction efforts on multiple levels including focus on obesity for the general population but the bts division focuses on those  highest risk for diabetes so these are very complimentary efforts and in fact we have focused much of our work in the native american community helping many many members achieve vouchers for nutrition foods particularly fruits and vegetables and the use of those vouchers has been an excess of fifty percent so a very tangible concrete example of a way to reduce those risk factors based on the findings of the lead diabetes prevention program clinical trial c is now actually translating those findings into practice we are able to do this with our partners at the top of the leading role as m c a of usa and united health group and we're able to offer this for about two hundred fifty to three hundred dollars a person this is the first time ever that a private health insurer has joined forces with a national community based organization to deliver this work and we're focusing on training the workforce recognizing those programs for quality assurance for actually investing in delivery of the programs and for health marketing so people know where to go and how to get those programs we're also preventing complications from diabetes and we have research trials that we've been doing the triad study we're taking those findings and we're working with our state based diabetes prevention and control programs to actually put those into practice and change what health care systems are actually delivering as a result of that study i want to just close with two new projects that we have going on that are exciting and one is the national program to eliminate diabetes related disparities in vulnerable populations we will now be funding six organizations that will focus on reducing the mortality and premature mortality and morbidity and we will be helping this by helping these communities to organize plan and implement effective strategies and finally we'll also be initiating a new platform of research studies to examine the impact of population targeted policies emanating from health systems business and community organizations and the government so so steps have been taken to improve the diabetes epidemic work and risk factor reduction must continue so fewer people develop pre diabetes the programs and policies for obesity prevention and control are critical there is a critical need for effective programs that prevent people with pre diabetes from developing the disease and the first steps have been taken in the form of a national diabetes prevention program the complications of diabetes have a very high cost in terms of dollars and human suffering and while improvements have been made and much work remains to be done especially vulnerable population thank you thank you dr albright dr frank and thank you mr chairman and members of the subcommittee and i also want to thank you for your congratulations on our sixtieth want to thank her i'm also very pleased to testify with dr albright because our two agencies work so effectively together on multiple efforts to combat diabetes including our national diabetes education program which is led by the two agencies on behalf of an idea and the and i am pleased to report that we are vigorously pursuing research on diabetes and its complications and today i would like to tell you about some of that and i supported research including research supported by the special statutory program for type one diabetes research which is administered by an idea and has resulted in many scientific advances that are improving the health and quality of life of people with diabetes a parallel funding stream the special diabetes program for indians is administered by the indian health service and has led to substantial improvements in diabetes in american indians mr chairman the need to pursue research on prevention treatment and cure of diabetes is greater than ever because the rates of several types of diabetes are rising the good news is that we've made tremendous progress in recent years which has lead to improvements in survival and quality of life for people with diabetes for example now thanks to continuous glucose monitoring technology some parents of young children with type one diabetes can sleep through the night without having to rise repeatedly to check their child's level the device measures glucose every several minutes and sounds an alarm at the levels are too high or too low a technological piece of mind allowing  parents to sleep more soundly because genetic an antibody test can predict with great accuracy which children will develop type one diabetes we can now test prevention strategies and are doing so to find new approaches to prevention we launched the teddy study the researchers screened over four hundred thousand newborns to find eight thousand who had genes that put them for particularly high risk of type one diabetes those children are now enrolled in th study and are being followed until age with the goal of identifying environmental triggers of type one diabetes for example if we couldn't find an infectious trigger we might develop a vaccine to prevent the disease the number of children who have developed auto immunity in type one diabetes are exactly as predicted in the study showcasing the tremendous power of these predictive tests we can prevent or delay the development of type two diabetes in people with high risk of disease as demonstrated by the end i did lead landmark diabetes prevention program clinical trial that dr albright mentioned a modest amount of weight loss through diet changes and moderate exercise substantially reduce the occurrence of type two diabetes at three years and now in the most recent report at ten years after enrollment in the trial this intervention worked in all the ethnic and racial groups studied in both men and women and in women with a history of diabetes building on the success and i do support research to translate these results to people who can benefit from them for example just this week and i did support it scientists announced exciting results from research in which community health workers effectively delivered a group based lifestyle intervention to people at high risk for type two diabetes at one year the participants lost as much weight as was observed in the diabetes prevention program suggesting that this approach may be a low cost way to reach americans provided information about how the c d c is building on the results of this and idea supported research to improve the public health by implementing a national diabetes prevention program diabetes during pregnancy brings risk to mother and child i support of hyperglycemia an adverse pregnancy outcomes study we now have precise information on what blood glucose levels should be during pregnancy to avoid complications near birth these are just a few examples have how far we've come in recent years through vigorous support of research toward increasing knowledge about diabetes and improving the health of people with diabetes however much work remains to be done to curb the diabetes epidemic for example it's critical to move beyond continuous glucose monitoring technology and link monitoring to insulin delivery to create the so called artificial pancreas this technology could help patients achieve control that has been shown to reduce complications and also alleviate the burden of here now that we have thousands of samples collected through the teddies study it's vital to use new and emerging technology to analyze the samples and identify an environmental trigger of type one diabetes building on the success of the many new available therapies for type two diabetes comparative effectiveness research can help inform doctors decisions about what medications for their patients and when loss of the insulin producing beta cells underlies both type one and type two diabetes research through an idea biology consortium may develop new approaches to treatment by providing insights on how to reprogram cells to become insulin producing cells stimulate beta cell replication or replace lost beta cell function with cells derived from stem cells complementing these efforts clinical research can provide information on how best to preserve beta cell function in people newly diagnosed with type one or type two diabetes perhaps most important to combating the diabetes epidemic is reversing the trend of both type one and type two diabetes occurring at younger ages because earlier disease onset means earlier development of complications and premature mortality for women earlier development of diabetes also in dangers or offspring the intrauterine environment plays an important role not only in problems at the time of birth but also in the obesity during the childbearing years and pregnancy implementing research findings into clinical practice has led to reductions in rates of heart disease kidney failure and blindness in people with diabetes by building on recent advances in diabetes research are poised to realize even greater improvements in health and quality of life for people with diabetes we have come far but we must go farther thank you mr chairman for your leadership in calling this hearing to focus attention on the problem and for your continued support of and i tha interagency coordinating committees in the midst of finalizing a diabetes research strategic plan the first comprehensive research plan to be released in several years anderson and is going to describe the future direction for ten major diabetes research areas and dr fradkin if i could start with you can you briefly summarize the major focus areas of this report and then i was going to have dr albright she identifies increasing rate of new diabetes cases as an area of great concern for c d c so how do you think that plan will help stem the diabetes epidemic i'll start with dr frank and thank you so and i did a k is pleased to chair the d m i c c which includes participation from c d c and multiple agencies across h s and throughout the government and really serves as a very effective organization to bring us together to share information and develop plans so we have developed with the help of over one hundred  journal researchers chapters focusing on each of eleven critical opportunities in the range from very basic areas such as auto immunity and the beta cell function that i would tell you about two needs with regard to  comparative effectiveness research and translational research to build translation from clinical research into translational research and we have identified a number of opportunities for important clinical trials that we would like to undertake if funds are available as well as some opportunities utilizing new proteomics technologies to try to cases here certainly of continued research that needs to be done and developing ways to reduce the onset of diabetes and those that have pre diabetes and reducing the risk factor so people don't even enter into the world of pre diabetes particularly th trend there will be certainly chapters in this plan that will help with those more basic biologic mechanistic work which is critical but importantly this plan also includes a chapter on translational research and that's an area that c d c and i h and others share we both have to play in the translation of the basic science into practice so there will be questions and guidance in that chapter for how to identify those areas that are real world in which you take what we learned in a laboratory or in a contained setting and now you've got to take it out to the real world so it's important that we have studies that allow us to make those transitions and then certainly from c d c s perspective we then take that information and try to dale it and sustain it and be sure that there much broader reach otherwise the discoveries that we made end up with a very limited reach and that's not a factor for the investment in research we need to be sure that we get it out to as many people as we possibly can all right dr robyn let me ask you this you talked about  you know trying to promote fresh vegetables fresh fruit that type of thing you know i actually am still the vice chair of the native american caucus and i've taken an interest in you know diabetes as pertains to native americans in particular and also in urban areas and i've always felt that you know the biggest problem is you know not having access to fresh fruits and vegetables we i know that i'm in i remember when i went to the hotel odum reservation years ago and you know they were desert people that relied on just you know nuts and fruits and things they gather in the desert and all of a sudden they're eating you know processed cheese and tacos and all this kind of stuff and and i know that they have made an effort there to try to go back to some of the you know subsistence agriculture but it's often difficult for people you know like i know i take my kids to mcdonald's one day i was at mcdonald's and i just you know in mcdonald's is now starting or like salads and fruits and different things that are better but if you stand there for half an hour nobody orders any of that is still what are the burgers and everything so how do you how do you promote this effect y and also is there are alternatives like you know some people suggested that maybe use dietary supplements vitamins because people don't take are going to you know eat the fresh fruits and vegetables are some way other way to supplement their  diet you know through vitamins or whatever i don't know i just seems like we're even though there are a lot of people out there trying to you know to promote the fresh fruits and everything that we continue to lose the battle not just among native americans but just in general i mean i know it's sort of a comment but if you could just how do we get there and are there alternatives like supplements that can be used instead i think that some of the things that we are trying that have evidence basis behind them and that's first important that what we do try has an evidence basis behind that i think part of the challenges that we haven't been able to implement these on a large enough scale to have big impact we do have to change the culture and change the environment so that the healthier choice is the easier choice for people and that can have to do with pricing strategies and other kinds of things that make it easier so it's availability both from a geographic you don't have to hike ten miles to get an orange when you can reach right next to you and get they may have a role to play of people are not getting adequate nutrition but really our major challenge is that people are over consuming calories so we do have to consider ways to reduce caloric consumption resulting in the obesity epidemic and increase the physical activity opportunities which is another situation where people need to have safer places to be physically active and know what they can do to improve their health so well there certainly are supplements and vitamins and to this section shows a positive benefits of lifestyle intervention diet physical exercise to individuals with type two diabetes plus it has been known that the diet plays a major role in treatment and management of type one diabetes and we talking about that in fact insulins affecting us requires dire interventions to manage diabetes and slow the progression of diabetes kovar bit more baby more primarily cardiovascular kidney and eye complications again something that we were you were just referring to i was chairman so this is a question directly about the registered dietitian who provide medical nutrition therapy which for decade since the benefits improvement protection act as a lot of us like to will say past has been a medicare part b cover intervention for diabetes chronic kidney disease under the health care law the affordable states that payment and deductible p s are way for the prevention interventions recommended by the u s preventative services task force with a grade a or b c m s recently released proposals rules for section forty one for the medical nutrition therapy was given a grade b so the u s preventative services task force recommends intensive behavioral diet counseling for cardiovascular and other diet related chronic describing which are education and counseling those are important services they will have limited impact if they're not undergirded and supported by other interventions that focus on making  activity it makes it more difficult to implement the advice that they're being given by their registered dietitian whether it's for hypertension or for diabetes so there are other opportunities to help support that education and counselling so that it can actually have the best impact it could possibly have but it does need to be supported by these other options and other sorts of things that allow people to make that choice the healthy choice much easier for them to make and i big concerns of the diabetes caucus for a long time has been the disparities between minority populations like african americans latinos and american indians and alaska natives and and anglos and we're not really sure why those disparities exist other than a combination of factors of health access community environment genetics so i'm wondering if you can talk a little bit more about any ongoing research  to address the causes of the disparities and how we find out the cause we can't really address how to deal with it so we should really look at that bill to us as we move along i want to ask dr albright you very briefly about this new report that came out from the robert wood johnson foundation this last this week and unfortunately it's called fs for fat and it says that the intensity the rate of obesity continues to increase in two thousand and ten particularly in the hispanic and african american sub populations and this is despite all the c d c s public health campaigns to improve diet choices the neck titties and everything else i'm wondering what c d c strategy is to try to reverse this trend i know c d c has been working assiduously on it but it just seems every time we get one of these reports is worse and worse my state of colorado is almost always the best state but that doesn't mean it's good because it just means that the rate of obesity is lower than other places that doesn't mean people aren't obese i'm wondering if you could talk about about how we can ramp up our efforts to reverse this trend and certainly a significant issue and one that's going to require a multi pronged approach i think that's one of the things we all have to remember is that there isn't a simple single answer for this it is multiple multi factorial other divisions within c d c and other agencies  federal government are certainly tackling and taking on obesity particularly working on childhood obesity so starting early in life and trying to change those habits early in life they're also working on things related to adult obesity prevention and treatment issues much of the focus is turning toward policies and changing the built environment that will help with that we there will need to be some time in order to determine the impact of those broader changes in policy a much bigger impact on a larger segment of the population thank you one last question for you dr frank going back to the special diabetes funding that we're trying to get reauthorized what benefits if any does the multigrain funding  that program provide to the ability to fund the most promising research in the field and how important is that multithreading aspect of the program let me give you an example of one thing that we did with the special funding that absolutely required multi year funding we created a program for career development research career development for researchers studying childhood diabetes so we gave funds to the institutions that had very very strong programs in pediatric diabetes research which enabled them to recruit in promising new investigators with the promise of five years of career support and i can tell you that some of the people supported through that program have already made tremendous khans contributions so for example at yale one of the investigators who was supported through the program has already got funding and is working on trying to close the loop and in fact three out of four of the people supported that yellow are now junior faculty there we had to stop that program because we don't have five years of funding remaining and so as a result we couldn't offer people five years of career development support that's just a specific kind of an example but i think it kind of gives the flavor of why it is important and many of the things that we're doing right where we have to follow kids until they  with pre diabetes where the quality of evidence that it would require for them to recommend supporting that would require many many years because simply identifying people with diabetes or pre diabetes doesn't rise to  so i think this is where the kind of joint effort that dr albright and i have been talking about is particularly important we ed and i are doing research to try to figure out how to most cost effectively prevent diabetes in those patients we have a very strong program looking at multiple different ways to achieve prevention and specifically looking at culturally sensitive approaches looking at what works best in particular populations and then and actually it's wonderful to see even private payers you know building on the results of our research to try them to create public health programs that give people access to the things that the research has shown was effective but clearly our research shows that about ninety percent of people with pre diabetes don't even know that they have pre diabetes and most of them are not taking effective steps to try to reduce the risk  that can be done to prevent cases from progressing at this point the evidence that we have suggests really scaling up and making this national diabetes prevention program widely available to people we are now offering c is providing funding to eleven sites united health group is providing it to six they have agreed to take over coverage of their beneficiaries with a very good public private model will get the ball rolling in some of these locations and the private insurer can take over and continue to reimburse as time goes on and so that's a nice combination but we do need to get to more places and get to more locations particularly harder to reach places we need more entities that can deliver this in addition to the usa who is outstanding and other additional third party payers so we've got the beginning infrastructure there and it's time now for us to expand that infrastructure and allow it to have reach across the country thank you got all bright  we work to pay special attention to that we first look for the best applicants certainly that's number one but we are working in always to assure a wide representation of states and more territories and specific jurisdictions as well we do provide funding to all of the u s affiliated territories so we are eager to have them involved as well as make sure that there was diversity in  that's some of the reason why we when we haven't been able to make the impact in the african american native american has been to communities i've been supporting having an executive order similar to the one that the president president clinton issued back in ninety eight i guess around environmental justice requiring that all agencies of government all the departments do health impact  assessments on their policies and programs and actually go beyond that to try to address some of the social and economic environmental issues through their policies do think that is that something that you could both support because it seems as though we're not going to make any progress as long as people live in food deserts have you know all of the socio economic  environmental barriers to improving their health i can certainly say that c d c s focus is growing in that area under the leadership of our agency director dr tom frieden we certainly are focused on policies and consider and evaluate the kinds of things that we are doing to try to make inroads in these very broad areas in our society but it's critical that we do investigate and find solutions within these multiple areas maybe i could just speak to one specific investigation that we have done in this regard that we actually just reported the results on the past week and that was a huge study in which we looked at the environment in forty two middle schools focusing on schools that predominately serve minority and low income students fifty percent were hispanic over twenty percent were african american most of them were on free or reduced lunch and we looked in th schools at changing the food services increasing physical activity and also promoting behavioral change and we got some some positive results we didn't get every where we wanted to be but we saw a reduction in obesity in the kids who started overweight or obese which was happy kids and they were overweight or obese and those children had reduced obesity as a result of this intervention decreased waist circumference decreased levels of influence so you know some positive impact on risk factors for type two diabetes and this is the kind of societal intervention that i think you know and i like to you know do do research to you know test and then when we you know when we see results from studies like this you thank you mr space for eight minutes thank you mr chairman and thank you again for exhibiting your commitment to such an important issue by convening  that this is visiting upon our country and just doing a little bit of quick math assuming that we're somewhere north of two hundred billion dollars a year now which i know is probably true i know the a d a s study from a couple of years ago two thousand and seven was one hundred seventy four billion that computes to over half a billion dollars a day two thousand and nine we spent a hundred forty eight billion dollars on two wars in this country and now we're spending upwards of two hundred billion dollars a year dealing with the effects of this one disease that is taking several different forms is it a safe assumption that with the increase in inciden of diabetes that these costs will continue to escalate  yes that would be the short answer and the much of the costs associated with diabetes consists of treating the complications of diabetes they certainly they certainly are associated with the cost of treatment fortunately as we've said there are ways for us now to prevent and we've been trying to work to get those to be delivered at cost effective profitable so with the livery of those preventative mechanisms and maintenance mechanisms in the end some little parameters you have to put around there when you are looking at cost effectiveness you're very right but you do have to look at the time horizon and you have to look at the assumptions but there certainly are opportunities for us to drive the cost down treatment and prevention so that we cure can take many different forms it could be an artificial cure like a closed loop system that you've referenced work could be a more natural cure perhaps someday with embryonic stem cell research if if you've got a young person that develops diabetes at the age of six or seven years old who was diagnosed with type one the complications that that child is likely to experience as a result of the disease are not likely to manifest themselves for decades that's right so that the time a child is forty or fifty years old his risk for heart disease blindness stroke kidney disease is much much higher than it would be for someone who's not  diabetic what i'm trying to drive out here is the future costs of this disease as debilitating as they are today you know society in a country that can't afford the luxury of  hundred billion dollars a year on one disease as debilitating as these costs are today can you give us some projection as to where we may be in twenty years or thirty years given the rather rapid increase in incidence of both type one and type two diabetes in the event that we do not see a cure and we not see the implementation on a wide scale of some of the measures you're testifying about today with maintenance well i think obviously the c d c is predicting that one in three children born today and one in two minority children born today will develop type two diabetes  if if if we don't intervene and change things but i would like to point out that things actually there are some very real improvements in terms of the prognosis for people with diabetes that have effects on health care so because rates of diabetes are increasing so fast if it weren't for some of the effective things that we're to bring down the complications of diabetes we would be even greater cost than we're seeing today so for example even though rates of end stage kidney disease which is a huge expense for medicare are going up the actual proportion of people with diabetes who develop end stage renal disease is falling so if we weren't doing as we diagnose them earlier as we catch them more people have less people have undiagnosed diabetes we are going to have a bigger total prevalence or total population we want to drive that number down by reducing the new cases so that what resources we have can be delivered to effectively manage those people that have the disease and then hopefully over time not have a future of one in three and a devastating complication so we've got to make headway in preventing all forms of diabetes or treating diabetes because it also is where we will spend the cost yes it does cost to take care of people with the disease it does cost to prevent the opportunity to not have people suffer the ravages of this disease and continue to be productive members of society is a critical piece to be sure we keep in the discussion treat type two diabetes by increasing the body's sensitivity to insulin two new studies released earlier this week act adds to the body of evidence about the risk of heart attack stroke and heart failure among people who take these drugs and those are of course the very things we're trying to prevent with preventing by treating diabetes we have the f d a is holding an advisory committee meeting image ally with the safety of avandia will be under review and i think th professional opinion what are the implications of the of the recent studies and i just dr albright if you have anything else to add let me just say that there are now multiple different classes of drugs that are available to treat type two diabetes as a result of research and wrote a good as i'm avandia a good as and are members of one of those classes of drugs most of the drugs have been approved based on relatively short term studies that show that they're effective in reducing glucose but i think what we really need and what the strategic plan that the chairman referred to that the b m i developing is what we really need is head to head comparisons of the various drugs that are available for treating type two diabetes with longer term time frame looking not simply at bluecoats lowering but looking at what they do over the course of diabetes in terms of heart disease in terms of weight gain in terms of quality of life for people and we don't have we don't have those head to head comparisons and so most of the data like the current studies that you're referring to are basically analyses of observational studies they aren't the ideal for people who are taking avandia right right now because it appears that not only do we have to reduce the blood sugar about how we do it is very important obviously more and more research and studies scientifically based studies have to be done but in the meantime what do we tell well our response when we're asked and we are asking questions is that it is critical that people have a discussion with their health care professional because a doctor  reference there are other treatments in their particular risk can be very carefully examined and determined so it's important that people have a conversation with their health care provider because diabetes is a disease where you have to make lots of decision and it's imperative that you have a good discussion with your health care provider to make those decisions for you as an individual this really is a humbling reminder that we still have a lot to learn about diabetes and that we need to do that so thank you very  partisan way and what our act aims to do is lower the incidence of just a shell diabetes and prevent women afflicted with this condition and their children from developing type two diabetes and the legislation creates a research advisory committee headed by c to develop multi site just ational diabetes research projects to enhance surveillance provide demonstration grants to focus on reducing the incidence of just station or diabetes and expense basic clinical and public health research understanding preventing and treating diabetes to a closer than ever to a better fighting in curing the disease so congratulations could you tell me more please about the results of the hypoglycemia and adverse pregnancy outcomes study i guess it's a happy study and  find that expansion of basic clinical and public health research investigating just ational diabetes and obesity during pregnancy such as the such is our act would be useful to further develop the insights again from the  pregnancy outcome study i can't speak specifically to to the act but i can tell you that i think just a small diabetes is one of the most important problems confronting us in the area of diabetes because not only does it cause problems at the time of birth for both the mother and the child increasing rates of the sary and section and injury to the child but also it puts the mother at increased risk for subsequent diabetes our diabetes prevention program showed some very positive results in that regard but also we have data suggesting that the intrauterine environment puts the offspring at increased risk for diabetes and obesity so you can imagine the vicious cycle that can occur as type two diabetes occurs at younger and younger ages moving towards people developing just a general diabetes or even type two diabetes during their childbearing years then the offspring of that pregnancy not only has the risk from the parents but also has the increased risk convert can buy this adverse metabolic environment that also then increases the risk and so you can imagine sort of a vicious cycle where rates of diabetes will it will increase expanding rates so this is a cycle that we really need to break and i think that happens that he has given us some extremely important information showing that adverse effect of hyperglycemia in pregnancy occur at much lower levels of glucose than we previously appreciated thank you very well said dr albright you mentioned in your testimony that women with type two diabetes certain creates risk having babies with birth defects and women with a history of station or diabetes should receive targeted intervention strategies to prevent type two diabetes before they become pregnant during pregnancy postpartum and  between can you please describe some of the intervention and educational outreach strategies the c d c is undertaking to increase awareness of diabetes and the risks associated with it briefly we are making special effort  to diabetes diabetes prevention program that we mentioned earlier to really push recruitment efforts and raising the awareness of women of childbearing years and their risk for developing type two diabetes and special efforts will be made to really try to seek to get them involved in this program they are terrific candidate for the national diabetes prevention program we also part of the national diabetes education program that doctors are up working on together we are working on some more just facial diabetes really appreciated and you know obviously something that we have to deal with long term but we appreciate your testimony and what we're going to do is take we're voting now we have three votes should take us to approximately one thirty so if anybody wants to have lunch we will reconvene at one thirty and we'll have our second panel thank you committee stands in recess the subcommittee will reconvene and as i promise we will begin with our second panel let me introduce each of you first is chairman buford rowland who is vice chairman and nashville area representative for the national indian health board and also chairman of the porch and creek indian thank you for being here then we have dr robert goldstein who is senior vice president for scientific affairs of the juvenile diabetes research foundation and dr robert r henry who is president elect medicine and science of the american diabetes association professor of medicine at the university of california department of medicine and chief of the section of n doctrine ology metabolism and diabetes at the v a medical center in san diego i need to mention to the panel that  chairman roland is going to testify and then leave because he has to catch a plane in previous commitments but he will take written questions and the way we work as i think you know we have five minutes opening from each of you and then we take questions but you can submit additional written statements if you like and then members may also follow up with some written questions as well so we'll start with chairman rowland nice to see you again this for example eleven percent there's eleven percent decrease in the blood sugar level a once in indian people who have been diagnosed with diabetes this translates to a forty percent thank you chairman and thank you i know that you have to leave but i do appreciate your testimony and i want you to know that i speak for myself but i think i can speak for everyone in saying that you know we're particularly conscious of the impact o of the subcommittee thank you for the opportunity to testify i'm robert goldstein senior vice president of scientific affairs for the juvenile diabetes research foundation and i'm honored to be here today before this committee with my colleagues from the diabetes community the largest charitable fund or an advocate of diabetes research worldwide since our founding forty years ago by parents of children with type one diabetes awarded more than one point four billion dollars to type one diabetes also known as juvenile diabetes is an auto immune disease for which there is no cure or at least not yet it is the second most common chronic disease affecting  focused on curing a particular disease yet this tremendous advances there is still much work to be done on behalf of the millions of families affected by diabetes i thank the committee for its leadership on strong support for the special association my full written testimony has been submitted for the record in the five minutes i have i will summarize that i've just come from the american diabetes association seventy of scientific sessions conference in orlando florida the world's largest diabetes research meeting where over fourteen thousand diabetes researchers providers and educators gathered to hear and discuss the latest in diabetes research the c d c is  diabetes as a disabling deadly epidemic that is on the rise between one thousand nine hundred eighty and two thousand and seven the prevalence of diabetes has increased by three hundred percent its total cost is over two hundred eighteen billion dollars a year research projects on type one type two diabetes and just a final diabetes have been funded by the american diabetes association in two thousand and nine the association awarded thirty three point five five million in new research support we strive particularly to bring research to the bedside and swiftly into the hands of patients and care providers we fund cutting edge research association funded work develop the first handheld blood glucose meters a key tool to achieving diabetes control currently our research has found a potential new treatment for diabetes diabetic retinopathy a complication that makes diabetes the number one cause of adult onset blindness we value our partnerships with health organization and i'm pleased to point to our continued work with a d r s in the development of an artificial pancreas that holds a promise of revolutionizing diabetes management for type one diabetes we are committed to developing the pipeline of diabetes researchers including funding younger researchers and more minority investigators to ensure the vitality  future research we've made great progress but more has to be done with this in mind i want to walk the line several key next steps in the battle to stop diabetes more attention must be paid to the pressing needs of special populations particularly affected by the diabetes epidemic including minority populations we remain steadfast in our efforts to support research that addresses these disparities r three six six eight sponsored by representative diana de gette that mike castle helps address this issue by renewing the special diabetes program s v p programs in american indians and american native communities funded type one research are highly successful the program expires in two thousand and eleven and i urge congress to pass this legislation soon so this work can continue hundred ninety five the eliminating disparities and diabetes prevention access and care act also seeks to address racial and ethnic health disparities related to diabetes we thank representative to get again for introducing this bill and representative donna christiansen for including it in the tri caucuses health disparities legislation we also must increase efforts to prevent and treat just a journal diabetes represent representatives eliot engel michael burgess has sponsored h r five three five four the gestational diabetes act which aims to lower the incidence of gestational diabetes in order to protect mother and baby and prevent future cases of type two diabetes our collective fight to stop diabetes must be continued your leadership in combating this growing epidemic is absolutely essential thank you for your commitment to the diabetes community and it would be my pleasure to answer any questions you might have on these important issues thank you again thank you dr hunter we're going to have questions from the panel and i'll start with myself goldstein can you explain how the promising research you're doing with the and i h and the private sector on the on initiatives like the continuous glucose monitor artificial station so if you want to follow up on him and then get into that well i would say with that i agree with everything that dr goldstein has stated and clearly what the goal for an artificial brain creates is to make it easier to be able to regulate the blood glucose within the normal limits and as you heard complications are minimal or minimized by good glycemic control particularly low blood sugars hypoglycemia which can have devastating consequences as well as persistent high blood sugars which leads to complications so these can be minimised by feedback between understanding the blood glucose levels and and injections of of insulin the other thing that we've found is that the research the long  term the funded by the and i d d data showed is that there were a legacy effect so that controlling diabetic patients today with type one diabetes had effects on cardiovascular disease beneficial effects on cardiovascular disease ten years later so that there was just short term study rafted for several years but even ten years later there were significant benefits so i think that it emphasizes a good control now as well will not  only reduce the long term consequences but they will they will have sustained benefits for many many years in terms of the second question can i ask you to repeat that i may forego that because i did want to add something else i know and i'm so interested in the issue as it affects the native americans and chairman role and left but i just wanted to ask you know he gave me the impression that that we really were getting a handle on diabetes some months to american  indians is it is that i mean i mean obviously there is some success but you know my recollection is talking to different tribes is that the incidence of diet still on the increase in particularly monks younger  how do i reconcile that with what he said i mean he's not here so it's difficult but i'm sure i'd be happy to see i think i think you're correct that the prevalence continues to rise in the indian and the native alaskan population however we're doing a better job of taking control of those people so the lasting they're living longer but we're doing a better job of preventing the complication more people are still contracting diabetes but you're able to control it and make them live longer and many of the in your statement you talked about technology and use and i know in the early part of the decade there was widespread media reports on the promise of this  with type one diabetes and health fully living the hope was that they would be able to live without daily injections of insulin and you did talk to you briefly mentioned one case what is the the transplantation programs in miami they recovered from the soldiers damaged sent them to walter reed they were transplanted back and he now has function doesn't have diabetes because of that be able to do it in large more larger populations of patients and of course to the research needed to make it more user friendly right now the artificial pancreas is that were that have been recommit probably at least an hour so we're going to try to finish so we go to ms capps next thank you very much for your testimony also for your patience getting to this very long day two questions that the incident has increased particularly among children under four i wonder if you could give us a couple of reasons for that if they're known i wish i could give you a couple of now or some kind of  years from both europe and the united states is unfortunately we're seeing it in younger and younger children in a more aggressive version and since nothing much has changed in the genetic structure of people that's related to something in the me move on because you describe also the disproportionate burden of type two and gestational diabetes and certain groups i wonder if this also holds true for type one and can you tell us whether there are certain age groups on children under that are particularly affected dr albright was talking about in testimony that c d c is actively working with the first lady and let's move that campaign to provide expertise in healthy eating and physical activity the way to deal with diabetes  and and they are also sponsoring the diabetes diabetes prevention program master trainer curriculum i'm particularly interested in types of prevention research and activities that will really work and that ties into areas like that they would work with with do with particular community groups and dr henry maybe you can tell us more about some efforts that you are as a sion is getting behind and the advocacy community is working on in terms of outreach specifically how they're being tailored to meet the needs of individual communities i think one of the major ways is in the application of the diabetes prevention program information which was highly effective and you know a fifty eight percent reduction in the development of diabetes in vigils who are able to lead a healthy lifestyle so clearly one can make big inroads in that now the task has now been to take it to the community level it has been done that translational pro part of that program has been has been initiated and we're obviously very supportive of that and it's been done for a reasonable amount of money as you heard in the range of two hundred fifty to three hundred dollars per year per person which is a reasonable amount of an expenditure so i think that that's right now where our major efforts are going but there are also many preventative and efforts that are being directed truly at cells which not only does it does it decline and see some type of type one diabetes but it declines progressively in type two and is a major contributor to many of  complications to poor glucose control so they are is again a great deal of research focusing on on preserving the beta cell and preserving and also treating the insulin resistance that you heard about because we now know that efforts directed at treating the insulin resistance whether it be through lifestyle modification or through medications prolongs the pancreas and gives it a longer period where it can produce sufficient insulin to maintain glucose control actually twice the incidence of diabetes than the national average or even the statewide average and i'd be interested in your thoughts as to whether those types of demographics location or access to health care facilities or poverty whether or not they have a negatively influenced diabetes incidence rate and whether your studies are accounting for that and what can be done to only obesity but different forms of obesity that precede the development of at least type two diabetes and individuals at risk for gestational diabetes and certainly those populations they need to be effectively treated think that that also increases the likelihood that individuals with a genetic risk of diabetes which it is a clearly has a genetic component are more likely develop diabetes so i think that those are real issues that have to be addressed and and i think that better access to preventative technology as well as as better treatment of the co morbidities will translate to a reduction in the development of diabetes thank you and dr goldstein thank you by the way for meeting with me earlier today taking time out of your busy schedule we have about two minutes and i'd i'd like your if you could give us just a very brief account of  so we're not funding the same thing and i would say the most important piece of information which has made a historically important investment in basic science  modest program to encourage small companies to develop things we like to nurse them along the pathway to get into a proof of concept clinical trials which is about the first large form of comes interested after you've already got some data along really hard to get money to do that venture capital has dried up and the foundation world has said that's a gap we need to think about selling how could we do it and that's exactly where we're focusing our way we work is we have about ten days to submit written questions and particularly since the chairman role and had to leave i'm sure there'll be some in the clerical send you those and then we'll get back to us as quickly as possible but again thank you and i know there's a lot more to be done on this issue but at least we had a beginning here today and without objection this meeting this committee