Faces of Public Health: Dr. John Buse
John Buse, MD, PhD, director of the Diabetes Care Center and chief of the Division of Endocrinology at the University of North Carolina at Chapel Hill School of Medicine, was just recently named the new chair of the National Diabetes Education Program (NDEP), a joint program of the National Institutes of Health and the Centers for Disease Control and Prevention.
The role of NDEP, established in 1997, is to foster public and private partnerships to improve diabetes management and outcomes, to promote early diagnosis, and to prevent or delay the onset of type 2 diabetes in the U.S. Currently, nearly 26 million Americans have diabetes, and 79 million have prediabetes, which puts them at increased risk for developing type 2 diabetes and heart disease. Over the next decade, an estimated forty million more U.S. adults could develop the condition.
NewPublicHealth spoke with Dr. Buse recently about his new position at NDEP.
NewPublicHealth: What innovations might you like to try at NDEP?
Dr. Buse: I think the program has been remarkably successful over almost 15 years. NDEP has developed a lot of materials, and the focus now is on working through partnerships to get the materials out there to a greater extent. Our research unit at UNC has done a lot of work with the pharmaceutical industry and clinical trials in diabetes and cardiovascular disease and I do think there’s an opportunity to partner with industry. They provide materials to primary care doctors and health care systems to use in patient education. They generally develop those materials themselves. I think there’s potentially an opportunity to have them use the NDEP materials with the NDEP being sort of an honest broker in developing educational programs free of undue influence from the pharmaceutical industry. So I think that’s a potential opportunity. The resources of NDEP are pretty modest compared to the scope of the diabetes problem, so leveraging our little tiny budget through partnerships is really the way to have an impact.
And as universal health care coverage is slated to come into existence in 2014, the improved access to care will create lots of opportunities to improve diabetes care and the education is really critical in that process. Health care systems and insurance plans and legislatures are looking more and more carefully at diabetes and obesity as major areas of cost and expenditures.
NPH: Can you tell us the key mandates of NDEP?
Dr. Buse: The focus is really on prevention, and we think of that in several ways. Primary prevention, preventing the development of diabetes, but also secondary prevention, preventing people with diabetes from developing complications, and then tertiary prevention, preventing people who have complications from either developing end stage complications or disability related to those complications. So, NDEP really has a mandate to focus across that spectrum.
NPH: Do we need an entirely new approach to helping people protect themselves from developing diabetes in the first place? Or do we need to be doing what we’re doing, but more?
Dr. Buse: I think that it’s really a combination of both, but this is a huge area of controversy basically because the way our health care system is set up now, most of the resources are devoted to intervention in people with disease as opposed to prevention, and frankly, most of the resources are put into testing and intervention in the forms of drugs or surgical interventions and the like, and very little in behavioral change. NDEP has a bunch of materials that have been developed to help with regards to behavior change, which frankly is targeting overweight and obesity and sedentary activity as a technique to prevent diabetes, and I think those materials could be very useful to primary care doctors who now have a mechanism to get paid for intervention in this population.
NPH: Does diabetes prevention have a silver bullet?
Dr. Buse: To be honest, I think the silver bullet is education, motivation and behavioral change. But just because you have a silver bullet doesn’t mean it will work. It also depends on how you load it into the gun and deliver it to kill the vampire. How you do that is very complicated, and at NDEP, that’s largely been their focus for the last few years. There are amazing drugs that are available now, but the drugs are only so good. In the absence of any behavioral change, they’re relatively ineffective, at least in the long haul.
So, the behavioral change strategies I think are the magic that many primary care doctors and specialists have not been adequately instructed on or have become adequately familiar with their use. Hopefully NDEP can change that.
NPH: Is there a single greatest barrier, in your opinion, to improving the diabetes rates in the U.S.?
Dr. Buse: I think from my perspective, you can’t stress enough that probably the biggest barrier we face for prevention of diabetes and prevention of the complications of diabetes is access to care. But if it was that easy we would not have a problem with obesity. Everybody who is obese, and certainly everybody who has diabetes, if they could make their obesity or diabetes go away they would. They have all been told eat less and exercise more. If they could do it they would. So it turns out that achieving this kind of behavioral change is really, really, really, really difficult to do. So, first, if you don’t have good access to care you’re not likely to get the kind of behavioral education and support that is associated with successful efforts to control diabetes or to prevent diabetes. If you don’t have good access to care and you fail in that effort, the drug therapies that are required [to treat diabetes] and the screening to prevent complications are extraordinarily expensive.
A very interesting phenomenon that I’ve observed in my 25 years in practice is when I first started my office, the lobby of my clinic had people missing legs and with seeing eye dogs and white canes in it every minute of every day. I would see patients like that every day, and I simply have none now, and the reason is that at the University of North Carolina where I work, if you can get yourself to the front door basically you have access to drugs and doctors and procedures, and so we have very little in the way of real disability associated with diabetes, whereas when I talk to my colleagues who work in health care systems that don’t provide free drugs and free care, their indigent patients still often have a terrible time with blindness and amputation and dialysis and early cardiovascular death.
>>See a new CDC report on declining rates of diabetes-related amputations.
So, I think it’s pretty clear that access to care is the single biggest barrier for prevention of either diabetes or the late stage complications. So I’m very optimistic about what will happen in the natural history of diabetes over the next ten years should the Affordable Care Act persist. I think it’s important that patients realize that what needs to be done and they work with their health care team to achieve those goals. I think the prognosis is excellent for a full lifespan free of disabling diabetes complications.