Report to Congress on Leveraging Federal Programs to Prevent and Control Diabetes and Its Complications (2021)

2021

Table of Contents

Executive Summary.

Appendices.

105

Chapter 1: Background.

Appendix A. National Clinical Care Commission ... 105

Chapter 2: Methods.

Appendix B. National Clinical Care Commission

Subcommittees

108

Chapter 3: Foundational Recommendations to

Address Diabetes.

Appendix C. Summary of the National Clinical Care

Commission’s Recommendations

112

Chapter 4: Population-Level Diabetes Prevention

and Control

Appendix D. National Clinical Care

Commission Act

139

Chapter 5: Diabetes Prevention in Targeted

Populations .

Appendix E. National Clinical Care

Commission Charter

143

Chapter 6: Treatment and Complications .

Appendix F. Acronyms and Abbreviations

149

Chapter 7: Looking Forward.

103

Appendix G. References

152

Contributions

U S Department of Health and Human Services

Designated Federal Officers

Clydette Powell, MD, MPH, FAAP

(March 2018 — September 2019)

(September 2020—February 2021, interim)

Linda Harris, PhD

Kara Elam, PhD, MPH, MS

(September 2019—February 2020, retired)

(February 2021—September 2021)

Jennifer Bishop, ScD., MPH

(February 2020—September 2020)

Technical Advisors

Clydette Powell, MD, MPH, FAAP

Richard D. Olson, MD, MPH

(February 2020—September 2020, retired)

Commission Members

William H. Herman, MD, MPH

Naomi Fukagawa, MD, PhD

Dean Schillinger, MD

(Commission Chair)

(Subcommittee Co-Chair)

Jasmine Gonzalvo, PharmD, BCPS,

Ann Albright, PhD, RD (Former

BC-ADM, CDE, LED

Pat Schumacher, MS, RD

Subcommittee Co-Chair, retired)

Carol Greenlee, MD, MACP, FACE

Donald Shell, MD, MA

Shari Bolen, MD, MPH

(Subcommittee Co-Chair)

David Strogatz, PhD, MSPH

John Boltri, MD, FAAFP

Meredith Hawkins, MD, MS

CAPT Jana Towne, RN, BSN, MHA

(Subcommittee Co-Chair)

Shannon Idzik, DNP, ANP-BC, FAAN,

Howard Tracer, MD

Ann Bullock, MD (Former

FAANP

(Subcommittee Co-Chair)

Subcommittee Co-Chair, retired)

Ellen Leake, MBA

CAPT David Wong, MD, FAAP

William Chong, MD

Barbara Linder, MD, PhD

(deployed in response to

Paul R. Conlin, MD

COVID-19)

Aaron Lopata, MD

(Subcommittee Co-Chair)

CAPT Samuel Wu, PharmD

J. William Cook IV, MD, FACP

Barry Marx, MD

Ayotunde Dokun, MD, PhD, FACE

Report to Congress

2021

Executive Summary

The United States is confronting the COVID-19 pandemic. At the same time, another

health crisis challenges the U.S.: diabetes mellitus.^* Since the last federal commission on

diabetes issued its report in 1975, the diabetes epidemic has accelerated and grown,

affecting more individuals and families, and contributing to greater health care costs. With

appropriate population-wide strategies and individual-level interventions, diabetes can be

prevented in many cases and its consequences mitigated. The 2021 National Clinical Care

Commission Report to Congress and the Secretary of Health and Human Services outlines

recommendations to leverage federal programs to prevent type 2 diabetes and control

diabetes complications. The report contains evidence-based recommendations for (1)

reducing diabetes-related risks and preventing type 2 diabetes in the general population,

(2) preventing type 2 diabetes in targeted populations at high risk for its development, and

(3) treating and managing diabetes and its complications to improve the health outcomes of

individuals with the disease. Implementation of these recommendations will help improve

the health and quality of life of millions of Americans affected by diabetes, and help control

the rising costs of diabetes and its complications in our nation.

Prevalence and Health Impact

In 2018, more than 34 million Americans (about one in 10 Americans of all ages including

one in seven adults¹) had diabetes, and 88 million American adults (approximately one

in three) had prediabetes, a state of increased risk for type 2 diabetes and cardiovascular

disease in which blood glucose levels are higher than normal but not high enough to be

diagnosed as diabetes.² If current trends continue, one in three Americans will develop

diabetes in their lifetime.³ In the U.S., diabetes is a leading cause of blindness in adults,

kidney failure, and lower-limb amputations and is a major contributor to death including

death from COVID-19. Individuals with poorly controlled diabetes have at least a two-fold

greater risk of death from COVID-19. Both diabetes and its complications are more common

and more severe in low-income Americans and Americans of color.

Economic Burden

The cost of diabetes poses a financial burden on the U.S. health care system and on society.

The total cost of diabetes was $327 billion in 2017, including $237 billion in direct medical

* Some of the issues discussed in this report are relevant to all types of diabetes, and some are specific to type

2 diabetes or type 1 diabetes. For issues and recommendations that are relevant to all types of diabetes, this

report uses the general term “diabetes.” For statements that are specific to type 1 or type 2 diabetes, this report

uses the term “type 1 diabetes” or “type 2 diabetes.”

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costs and $90 billion in reduced productivity.² About 67% of diabetes costs were paid by

Medicare and Medicaid.⁴ Caring for people diagnosed with diabetes accounts for one of

every four health care dollars, making diabetes the most costly chronic condition in the

U.S.^{4, 5}

Diabetes Is a Medical and a Societal Problem

Type 2 diabetes can be prevented in many cases and medical care can help individuals with

diabetes avert many of its complications. However, the social and environmental conditions

that shape people’s daily experiences have a huge impact on whether people will develop

diabetes or suffer from its consequences. Thus, the Commission approached its charge

through the lens of a socioecological and an expanded chronic care model. It was clear

that diabetes in the U.S. cannot simply be viewed as a medical or health care problem, but

also must be addressed as a societal problem that cuts across many sectors, including food,

housing, commerce, transportation, and the environment. The Commission believes that

to effectively improve the health outcomes of people at risk for or affected by diabetes,

all of these elements must be taken into account. As a result, many of the Commission’s

recommendations are aligned with what is known as a “health-in-all-policies” approach.

The Commission’s Recommendations

Based on the information gathered and synthesized through a federal data call, stakeholder

input, public comments, and extensive literature searches and reviews, the Commission

developed evidence-based, actionable recommendations to address (1) diabetes

prevention and control in the general population, (2) diabetes prevention in populations

who are at high risk of developing type 2 diabetes, and (3) treatment of diabetes and its

complications.

Overarching Recommendations

Historically, diabetes prevention and treatment have been considered to be medical

problems requiring medical treatment. Limited attention has been paid to the social and

environmental conditions that contribute to diabetes and make managing diabetes more

challenging.

To improve diabetes awareness, prevention, and treatment, additional federal efforts are

needed to improve access to health care, address the social determinants of health, and

improve trans-agency collaboration. Accordingly, to formulate its recommendations, the

National Clinical Care Commission focused on each of these cross-cutting issues and made

the following recommendations:

• To coordinate and monitor federal efforts relevant to diabetes and to ensure trans-

agency collaboration, an Office of National Diabetes Policy should be created and

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given responsibility to develop and implement a national diabetes strategy across

health care and non-health focused federal agencies.

• Federal policies and programs should ensure that people at risk for or with

diabetes have access to comprehensive, high-quality, and affordable health care.

• Health equity should be considered in every new or existing federal policy or

program that impacts people at risk for or with diabetes. This is essential to

eliminate unintended and adverse impacts on health disparities.

Recommendations for Diabetes Prevention in the

General Population

To delay, prevent, and control diabetes, and to reduce racial, ethnic, and income-

related disparities in diabetes outcomes, changes need to take place in the social and

environmental contexts in which U.S. residents live, learn, work, and play. Fostering such

change cannot be left only to those federal agencies that are accountable for health care.

Large-scale success can only be achieved by also engaging those federal agencies whose

primary focus is not on health but whose policies and programs play an important role

in shaping the social and environmental contexts that influence diabetes incidence and

complications.

To address this critical need, the National Clinical Care Commission recommends

• Updating and increasing funding to the U.S. Department of Agriculture’s nutrition

assistance programs to promote both food security and dietary quality;

• Increasing breastfeeding rates through effective federal programs and paid

maternity leave;

• Implementing federal strategies to encourage the consumption of water over

sugar-sweetened beverages in the U.S. population;

• Updating the Food and Drug Administration’s food labeling policies and practices

to prevent and control diabetes;

• Providing the Federal Trade Commission with the authority and resources to

regulate the food and beverage industry’s marketing and advertising to children;

• Modifying federal department and agency policies to reduce environmental

exposures associated with diabetes in the ambient environment (air, water, land,

and chemical) and improve the built environment by enhancing walkability, green

spaces, physical activity resources, and active transport opportunities;

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• Expanding housing opportunities in health-promoting environments for low-

income individuals and families through the Department of Housing and Urban

Development’s programs; and

• Optimizing and expanding research programs that will enhance our understanding

of the social and environmental conditions associated with a greater risk of

diabetes and its complications, and evaluating the effects of changes in these

conditions on diabetes-related outcomes.

Recommendations for Diabetes Prevention in People

at High Risk

The Commission focused on several factors that have the greatest likelihood of preventing

the development of type 2 diabetes and its complications in those who are at high risk

for type 2 diabetes, specifically people with prediabetes. There are effective methods, in

particular lifestyle change programs, for reducing the risk of developing type 2 diabetes.

However, 85% of the 88 million Americans with prediabetes are not aware they have the

condition, and most people with prediabetes are not engaged in preventive interventions.

The Commission recommends

• Increasing awareness of prediabetes and availability of effective lifestyle

intervention programs, in particular the National Diabetes Prevention Program

(National DPP);

• Promoting better coverage of screening tests for prediabetes; and

• Adopting clinical quality measures that support screening for prediabetes and

targeted interventions to delay or prevent type 2 diabetes.

The Commission also recommends improving access to, participation in, and sustainability

of type 2 diabetes prevention interventions. These recommendations include

• Providing adequate insurance coverage for all effective delivery modalities for

diabetes prevention (that is, in-person, telehealth, and virtual);

• Approving the Medicare Diabetes Prevention Program (MDPP) as a permanent

covered benefit;

• Continuing efforts to streamline the recognition and payment processes for type 2

diabetes prevention programs;

• Improving payment models and payment levels for MDPP providers;

• Incentivizing state Medicaid programs to provide coverage for the National DPP;

and

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• Providing additional support for federal programs that focus on type 2 diabetes

prevention.

The Commission also recommends supporting research to develop new and better

methods for preventing both type 1 and type 2 diabetes.

Recommendations for Diabetes Treatment and Complications

The Commission focused on several factors that have the greatest likelihood of improving

the delivery of high-quality care to all persons with diabetes. The biggest gap in diabetes

treatment and preventing its complications is mismatch between available resources and

the needs of persons living with diabetes. The Commission’s recommendations for diabetes

treatment and complications are designed to bridge this gap.

• At the patient level, the Commission recommends reducing barriers and

streamlining administrative processes for receipt of diabetes self-management

training and diabetes technologies and devices, expanding access to virtual care,

and ensuring insulin is affordable and accessible.

• At the practice level, the Commission recommends enhancing programs that

support team-based care and developing capacity to support technology-enabled

interventions.

• At the health care system level, the Commission recommends aligning health care

workforce needs with programs funded by the Department of Health and Human

Services.

• At the health policy level, the Commission recommends ensuring pre-deductible

insurance coverage for high-value diabetes treatments and services and

developing a quality measure that enhances patient safety and reduces risk of

hypoglycemia.

The Commission also identified several areas that need additional research.

To improve the health outcomes and quality of life of individuals at risk for or with diabetes;

to protect the wellbeing of all American people; and to control our nation’s rapidly rising

health care cost, the Commission urges Congress and the Secretary of Health and Human

Services to take action to make certain that the Commission’s recommendations are

implemented and the results monitored.

Report to Congress

Chapter 1: Background

Diabetes in the United States

Diabetes Mellitus

Diabetes mellitus is a heterogeneous group of disorders characterized by high blood

glucose levels (hyperglycemia). Most people with diabetes can be classified as having type

1 diabetes or type 2 diabetes.

Type 1 diabetes accounts for five to 10 percent of diabetes in the U.S. It tends to affect

children and adolescents but it may be diagnosed at any age. In type 1 diabetes,

destruction of the insulin-producing cells in the pancreas leads to insulin deficiency. At

clinical presentation, people with type 1 diabetes often have marked hyperglycemia and

its attendant symptoms and signs including increased thirst, increased urination, and

unintentional weight loss. When a person is symptomatic, the fasting plasma glucose is

usually unequivocally elevated and the diagnosis of diabetes is straightforward. Insulin is

the only therapy for type 1 diabetes and it is necessary for survival.

Type 2 diabetes accounts for 90% to 95% of diabetes in the U.S. Racial and ethnic minority

populations are at substantially increased risk for type 2 diabetes as are older adults

and those with obesity, hypertension, high triglyceride and low high-density lipoprotein

(HDL) cholesterol levels, and family histories of type 2 diabetes. Women with histories

of gestational diabetes are also at substantially increased risk. Type 2 diabetes is often

preceded by prediabetes, a state of increased risk for type 2 diabetes and cardiovascular

disease where blood glucose levels are higher than normal but not high enough to

diagnose diabetes. Type 2 diabetes is caused by a combination of resistance to insulin

action and inadequate compensatory insulin secretion. In type 2 diabetes, hyperglycemia

sufficient to cause complications affecting the eyes, kidneys, and nerves may be present

without clinical symptoms. During this asymptomatic period, prediabetes and type 2

diabetes may be diagnosed by measuring fasting plasma glucose, plasma glucose after

an oral glucose load, or hemoglobin A1c (HbA1c), a measure of average glucose levels

over the preceding three months. Both lifestyle interventions and medications can delay or

prevent progression from prediabetes to type 2 diabetes, and both lifestyle interventions

and an array of oral and injectable medications, including insulin, may be needed to control

blood glucose levels in type 2 diabetes.

Some of the issues discussed in this report are relevant to all types of diabetes, and some

are specific to type 2 diabetes or type 1 diabetes. For issues and recommendations that

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are pertinent to all types of diabetes, this report uses the general term “diabetes.” For

statements that are specific to type 1 or type 2 diabetes, this report uses the term “type 1

diabetes” or “type 2 diabetes.”

Diabetes Prevalence

Someone in the U.S. is diagnosed with diabetes every 20 seconds. In 2018, more than 34

million Americans (about one in 10 Americans of all ages^{2, 6} including one in seven adults¹)

had diabetes. Of these, 26.9 million were diagnosed and 7.3 million were undiagnosed. In

addition, 88 million American adults (more than one in three) had prediabetes.²

The prevalence of diabetes increases with age such that 24.2 million or more than one in

four Americans 65 years of age and older have diabetes. In recent years, the prevalence

of both type 1 and type 2 diabetes has increased substantially among American youth.⁷ In

2016, nearly one in five adolescents had prediabetes, increasing their risk of developing

type 2 diabetes, comorbidities, and complications.⁸ Type 2 diabetes is more common

among low-income people and people of color, in whom prevalence rates are often twice

of their white counterparts. As such, diabetes is an important contributor to health inequities

in the U.S. If current trends continue, one in three Americans will develop diabetes during

their lifetimes.³ One of five Americans with type 2 diabetes and four of five Americans with

prediabetes are unaware of their condition.

The increasing prevalence of type 2 diabetes in the U.S. has been associated with dramatic

increases in the prevalence of obesity, which, like type 2 diabetes, can result from unhealthy

social and environmental conditions. In 1975, 14.5% of U.S. adults had obesity and 1.3%

had extreme obesity.⁹ By 2020, 42.4% of U.S. adults had obesity and nearly 10% had severe

obesity.¹⁰ Rates of childhood obesity have also increased over the years, with nearly 20% of

American youth two to 19 years of age having obesity.¹¹

Health Impact

Diabetes can affect the whole body. It is associated with a two- to four-fold increased risk of

cardiovascular disease, including stroke and heart attack, and causes unique complications

affecting the eyes (diabetic retinopathy), kidneys (diabetic nephropathy), and nerves

(diabetic neuropathy). In the U.S., diabetes is the number one cause of adult blindness,

kidney failure, and lower-limb amputations, and is a major contributor to heart disease and

death. Diabetes also contributes to death from infectious diseases. As an example, diabetes

increases the risk of death from COVID-19 by two- to three-fold.

Economic Burden

The cost of diabetes in the U.S. is enormous and poses a substantial burden to the health

care system and to society (Figure 1). The total cost of diabetes in 2017 was estimated to

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be $327 billion. This included $237 billion in direct medical costs (the costs of medical

care for people with diabetes) and $90 billion in indirect costs (the costs to society of lost

productivity due to illness, disability, and premature mortality).² Two-thirds of direct costs

of diabetes were paid by Medicare or Medicaid.⁴ Caring for people with diabetes in the

U.S. accounted for one of every four health care dollars, making diabetes the most costly

chronic disease.^{4, 5}

Figure 1. Change in total economic costs of diabetes in the United States, adjusted for

inflation, 2007-2017⁴

History of Federal Efforts to Combat Diabetes in the

U.S.

In 1974, “The National Diabetes Mellitus Research and Education Act” (Public Law 93-

354) established the National Commission on Diabetes. It formulated the Long-Range

Plan to Combat Diabetes in the United States.¹² The plan and subsequent federal actions

made a substantial impact on diabetes research, diabetes programs, and treatment for

diabetes and its complications. Basic biomedical research advanced knowledge of the

fundamental causes of diabetes and its complications and facilitated the development of

effective new therapies. Clinical trials proved that hyperglycemia causes the microvascular

and neuropathic complications of type 1 diabetes, and that intensive diabetes treatment

can delay or prevent those complications.¹³ Similarly, the Diabetes Prevention Program

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demonstrated the effectiveness of intensive lifestyle intervention and metformin to delay

or prevent the development of type 2 diabetes in high-risk individuals with prediabetes.¹⁴

Advances have also been made in devices and technologies to improve glucose control,

including insulin pumps and continuous glucose monitors. Exciting new treatments have

been developed to reduce the incidence of blindness, end-stage kidney disease, and

amputations.

The Long-Range Plan also helped establish several federal programs to address diabetes

and its complications. The National Institutes of Health (NIH) established Diabetes

Research and Training Centers to conduct research in diabetes, expand the diabetes

workforce, offer training programs, and provide continuing education. More recently, NIH’s

Centers for Diabetes Translational Research have facilitated translation of research into

community practice. The Centers for Disease Control and Prevention (CDC), the Veterans

Health Administration, and the Indian Health Service also established diabetes health

care, education, and control programs. Additionally, the National Diabetes Information

Clearinghouse and the National Diabetes Data Group provided accurate statistics on

diabetes to support public policy.

In the mid-1970s, CDC funded a demonstration project to build the infrastructure for

Diabetes Prevention and Control Programs in seven states. Over the ensuing two decades,

these programs expanded to include all 50 states, the District of Columbia, and several

U.S. territories and freely associated states in the Pacific and the Caribbean. In 1995, CDC

published the first National Diabetes Fact Sheet with the collaboration and consensus of

more than 10 federal agencies and national diabetes organizations. Today, CDC’s interactive

U.S. Diabetes Surveillance System documents the public health burden of diabetes and its

complications at the national, state, and county levels. In 1998, CDC and NIH began the

SEARCH for Diabetes in Youth Program to address the emerging public health problem of

type 2 diabetes in children and adolescents and the Translating Research Into Action for

Diabetes (TRIAD), a study of diabetes quality of care, costs, and outcomes in the U.S. CDC

and NIH also co-funded the NEXT-D Initiative to evaluate the effects of type 2 diabetes-

related health policies and interventions on various populations. In response to findings

from the Diabetes Prevention Program (DPP) and subsequent translation studies, CDC

launched the National DPP in 2012, with the goal of building a nationwide delivery system

for an evidence-based lifestyle change program to prevent or delay the onset of type 2

diabetes in adults with prediabetes.

Remaining Challenges and Emerging Threats

Although the National Commission on Diabetes stimulated progress, it has been nearly

50 years since it issued its report, and there is an urgent need to reassess and update

the federal response to the diabetes epidemic. It is time to consider how the federal

government can initiate or expand programs and policies to more effectively address the

growing problem of diabetes in the U.S.

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There has been increasing recognition that social and environmental factors influence the

risk of type 2 diabetes and make controlling diabetes more challenging.¹⁵ Individuals who

have less education, lower incomes, more food and housing insecurity; and who live in rural

areas have higher rates of type 2 diabetes and worse diabetes outcomes. Higher type 2

diabetes risk and worse diabetes outcomes are also associated with physical environments

that lack adequate playgrounds, parks, walkability, and transportation. Poor social cohesion,

marginalization, and poverty are also associated with diabetes risk.

Efforts to translate the advances in diabetes treatment into routine clinical practice have also

stalled. Only one in four adults with diabetes achieves recommended standards of diabetes

care,¹⁶ and this level of performance has remained unchanged since 2012.¹⁷ In addition, the

improvements in diabetes care have not been evenly distributed across the U.S. population.

The same racial and ethnic minority groups and lower-income individuals who experience

higher type 2 diabetes prevalence often have higher rates of preventable and costly

complications, including heart attacks, strokes, blindness, kidney failure, and amputations.

In the U.S., more than half of the preventable burden of diabetes is attributable to the

non-clinical social and environmental factors that shape health behaviors.^{15, 18, 19} The other

half is attributable to lack of access to affordable, quality care and to failings in the design

of our current health care delivery system—one that is more geared to reactive, acute care

than to proactive, team-based care. National efforts to prevent and treat diabetes have

been hindered by (1) failure to address social determinants of health; (2) lack of directives

for trans-agency engagement of non-health federal agencies and insufficient coordination

among all federal agencies (non-health and health agencies); and (3) persistent gaps in

access to health care.

Establishment of and Charge to the Natonal Clinical

Care Commission

In 2018, in response to the National Clinical Care Commission Act (Public Law 115-

80), the Secretary of Health and Human Services established the National Clinical Care

Commission.²⁰ The Commission included 12 special government employees and 11

individuals representing relevant federal agencies, who collectively provided expertise in

the prevention, care, and epidemiology of diabetes and its complications. The Commission

was charged with evaluating and making recommendations to Congress and the Secretary

of Health and Human Services regarding:

1. Federal programs of the Department of Health and Human Services that focus

on preventing and reducing the incidence of complex metabolic or autoimmune

diseases resulting from issues related to insulin that represent a significant disease

burden in the United States, which may include complications due to such diseases;

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2. Current activities and gaps in federal efforts to support clinicians in providing

integrated, high-quality care to individuals with the diseases and complications;

3. The improvement in, and improved coordination of, federal education and

awareness activities related to the prevention and treatment of the diseases and

complications, which may include the utilization of new and existing technologies;

4. Methods for outreach and dissemination of education and awareness materials that

a. Address the diseases and complications;

b. Are funded by the federal government; and

c. Are intended for health care professionals and the public; and

5. Whether there are opportunities for consolidation of inappropriately overlapping

or duplicative federal programs related to the diseases and complications.

The Natonal Clinical Care Commission’s Approach to Its Charge

The National Clinical Care Commission’s approach to its charge recognized that diabetes

in the U.S. is not simply a health condition that requires medical care but also is a

societal problem that requires a trans-sectoral approach to prevention and treatment.

Accordingly, the Commission approached its duties using a framework that combines the

Socioecological Model²¹ and the Chronic Care Model²² (see Figure 2).

The socioecological model highlights how societal factors, environmental exposures,

community attributes, and group characteristics interact to influence the health of

individuals. It is not possible to fully understand or improve health outcomes without taking

into account all of these elements. Sectors of influence considered by the socioecological

model include government, economic development, industry, labor, education, food

systems, the environment, housing, transportation, and communication and marketing.

Supportive environments at the community, worksite, school, and home levels also influence

individual health. And individual factors, including psychosocial factors, stress, trauma, diet,

physical activity, age, sex, and socioeconomic position further influence health.

Preventing and successfully treating diabetes is impossible if individuals do not have

access to comprehensive, affordable, and high-quality health care. The Chronic Care

Model identifies six categories of clinical practice change that can lead to improvements in

health outcomes for people with diabetes. These elements are (1) organizational support,

(2) clinical information systems, (3) delivery system design, (4) decision support, (5) self-

management support, and (6) community resources.

Those elements that are common to both community and clinical settings include health

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literacy, access to services and care, self-management support, organized peer support, and

the negative impact of discrimination.

Figure 2. The National Clinical Care Commission Framework for Diabetes Prevention and

Control: The Combined Socioecological and Chronic Care Model for Diabetes

The logic of the National Clinical Care Commission Framework is that diabetes can

be prevented or controlled only through supportive policies, social conditions, and

environments and by promoting more prepared, proactive health systems and practice

teams that enable informed and activated patients. The intended outcomes of these

structures and processes include improved clinical outcomes and quality of life for

individuals at risk for or with diabetes; better diabetes-related population health; and

greater diabetes-related health equity.

In the chapters that follow, the Commission first provides a set of overarching

recommendations that address federal efforts to ensure coordination of federal policies

and programs to improve the social and environmental conditions that influence diabetes

risk and outcomes, promote access to health care, and advance health equity. The

subsequent recommendations of the Commission are structured around the work of three

subcommittees that have addressed (1) diabetes prevention and treatment through federal

policies and programs that affect the general population; (2) diabetes prevention through

Department of Health and Human Services

Chapter 2: Methods

To develop evidence-based, actionable recommendations to Congress and the Secretary

of Health and Human Services (HHS), the National Clinical Care Commission formed three

subcommittees and gathered information through a federal data call, a systematic literature

search and review, stakeholder input, and public comments.

Commission Structure

Membership

The National Clinical Care Commission consisted of 23 members: 12 non-federal members

representing diverse disciplines and views and 11 ex-officio federal members. The

non-federal members included primary care physicians, clinical endocrinologists, non-

physician health care professionals, clinical pharmacists, patient advocates, and public

health experts. The federal members represented the Centers for Medicare & Medicaid

Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control

and Prevention, the Indian Health Service, the Department of Veterans Affairs, the National

Institutes of Health, the Food and Drug Administration, the Health Resources and Services

Administration, the Department of Defense, the Department of Agriculture, and the Office

of Minority Health. (See Appendix A: Commission Members).

Commission Chair and Subcommittees

At its first public meeting on October 31, 2018, the Commission elected a Chair and

discussed potential focus areas to establish subcommittees. After the meeting, the

Commission refined their focus areas and established four subcommittees.

• Prevention—General Population Subcommittee

• Prevention—Targeted Population Subcommittee

• Treatment and Complications Subcommittee

• Case Finding, Outreach, and Education Subcommittee

Commission members volunteered to participate in at least one of the subcommittees.

Each subcommittee had two volunteer co-chairs: one public member and one federal

Commission member (see Appendix B: Subcommittees).

As the subcommittees gathered information and prepared to develop draft

recommendations, it became clear that the work of the Case Finding, Outreach, and

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Education Subcommittee overlapped with the other three subcommittees. To reduce

duplication, the Commission decided in May 2019 to dissolve the Case Finding, Outreach,

and Education Subcommittee and address outreach- and education-related topics through

the other three subcommittees. Members of the Case Finding, Outreach, and Education

Subcommittee volunteered to join other subcommittees.

Information Gathering and Assessment

The Commission collected information on federal policies and programs relevant to

diabetes through a formal data call, literature searches, key informant and stakeholder input,

and public comments. The Commission also developed an overarching National Clinical

Care Commission Framework for Diabetes Prevention and Control and reviewed relevant

research that could inform their recommendations (see Figure 2, Chapter 1).

Each subcommittee developed a framing statement, identified priority focus areas,

reviewed federal agencies’ responses to the data call, sought clarifications and additional

information from the agencies, consulted subject matter experts, and conducted literature

searches. The subcommittees conducted regular meetings to hear stakeholder and expert

presentations and to discuss progress.

Relevant Agencies

To meet its charge, the Commission reviewed relevant programs and policies of federal

agencies and departments that deliver or pay for health care, conduct diabetes-related

research, perform administrative roles that impact diabetes care, or support diabetes-

related public health efforts. Recognizing that the diabetes epidemic in the U.S. is driven

in part by socioeconomic and environmental factors, the Commission also obtained

information from non-health agencies whose policies and programs affect diabetes risk. The

Commission considered the policies and programs of the following agencies relevant to

diabetes risk, prevention, and treatment.

Health Agencies

• Administration for Children and

• Department of Veterans Affairs

Families

• Food and Drug Administration

• Agency for Healthcare Research and

• Health Resources and Services

Quality

Administration

• Centers for Disease Control and

• Indian Health Service

Prevention

• National Institutes of Health

• Centers for Medicare & Medicaid

• Office of Minority Health

Services

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Non-Health Agencies

• Department of Agriculture

• Department of Treasury

• Department of Defense

• Environmental Protection Agency

• Department of Education

• Federal Bureau of Prisons

• Department of Housing and Urban

• Federal Communications

Development

Commission

• Department of Labor

• Federal Trade Commission

• Department of Transportation

Federal Data Call and Presentations

To gather information on federal policies, programs, and research relevant to diabetes, the

Commission developed a survey to systematically collect information. The data call was

distributed at the end of 2019 to the following agencies and departments.

• Centers for Medicare & Medicaid

• Agency for Healthcare Research and

Services

Quality

• Centers for Disease Control and

• Health Resources and Services

Prevention

Agency

• National Institutes of Health

• Indian Health Service

• Food and Drug Administration

• Federal Bureau of Prisons

• Office of Minority Health

• Department of Agriculture

• Department of Veterans Affairs

• Department of Defense

All of the agencies and departments that received the data call provided responses in the

first quarter of 2020. The subcommittees reviewed the agencies’ responses. When needed,

the subcommittees sought clarifications and requested additional information from the

agencies.

The subcommittees also reached out to relevant agencies and departments that did not

receive the data call. Agencies and departments that responded to the Commission’s

request and provided information through presentations and written communications

include the Administration for Children and Families, the Environmental Protection

Agency, the Federal Communications Commission, the Federal Trade Commission, and the

Department of Transportation.

The information gathered through the data call, subsequent communications, and

presentations helped the subcommittees formulate their recommendations.

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Literature Search and Review

Each subcommittee developed a list of questions to guide literature searches relevant to

their focus areas. Librarians at NIH conducted a series of literature searches based on these

questions and identified an extensive list of peer-reviewed publications. Subcommittees

reviewed the publications relevant to their work and used the findings to assess the federal

programs and develop recommendations.

Stakeholder Input

The subcommittees identified several stakeholder organizations whose missions

overlapped with the Commission’s charges. Input from these stakeholders was sought

through conference calls and written communication. Some stakeholders also provided

comment at the Commission’s public meetings and in response to Federal Register Notices.

In May 2021, the Commission sent their draft recommendations to all stakeholders with

whom subcommittees had interacted for their review and comment. The subcommittees

reviewed and discussed stakeholders’ written comments, and addressed them in their

recommendations or in the report, when appropriate.

Key Informant Presentations

The subcommittees also consulted key informants whose subject matter expertise was

relevant to the work of the subcommittees. From 2019 to May 2021, the Commission

consulted more than 50 experts through conference calls and written communication.

Public Comments

In compliance with Federal Advisory Committee Act (FACA) requirements, the Commission

provided the public with opportunities to provide comments through several channels.

• Verbal comments at Commission public meetings: At Commission public meetings,

time was allocated for the public to provide comments. Each individual had three

minutes to provide oral comments.

• Written comments submitted prior to Commission’s public meetings: Prior to each

Commission meeting, the public was invited to send written comments to the

Commission. This mechanism provided an opportunity for the public to share their

views and insights without attending the meeting.

• Email comments: The public had an opportunity to send written comments to the

Commission at OHQ@hhs.gov.

• Formal solicitation of public comment: The Commission sought public comment

through Federal Register Notices. Responses were submitted through

regulations.gov.

Report to Congress

The subcommittees reviewed all the public comments received and addressed them, when

appropriate, in their report and recommendations.

Work Process

The subcommittees met regularly and used an iterative process to refine priority

focus areas; discuss ideas for recommendations; and review, discuss, and revise draft

recommendations. The subcommittees reported their progress, shared their findings, and

presented draft recommendations at the Commission’s public meetings. Commission

members asked questions, provided input, and suggested changes to refine the

recommendations.

The subcommittees presented their recommendations at the Commission’s public meeting

on June 22, 2021. Commission members voted on the recommendations and formed

writing groups to write its final report to Congress.

On September 8, 2021, the Commission met to review and vote on their final

recommendations and report to Congress and the HHS Secretary. After suggesting minor

editorial revisions, Commission members unanimously voted to approve the final report

and recommendations.

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Chapter 3: Foundational

Recommendations to Address

Diabetes

Background

The charge to the National Clinical Care Commission is to evaluate and make

recommendations regarding improvements to the coordination and leveraging of programs

and policies within HHS and other federal agencies to improve the awareness, prevention,

and treatment of diabetes and its complications. Historically, the prevention and treatment

of diabetes have been considered to be medical problems requiring medical interventions.

However, it is clear that social determinants of health, lack of federal trans-agency

collaboration, and barriers to accessing care also impact diabetes prevention and treatment.

Accordingly, the National Clinical Care Commission formulated recommendations to

address social and environmental factors relevant to diabetes, trans-agency collaboration,

access to health care, and health equity.

Recommendations

Focus Area 1. Address Social Determinants of Health and

Improve Trans-Agency Collaboration

Background

In the U.S., type 2 diabetes is more common and diabetes is more consequential among

communities of color; those who live in rural areas; and those with less education, lower

incomes, and lower health literacy.² As early as 2012, the American Diabetes Association

(ADA), the Endocrine Society, the American College of Physicians, the American Academy

of Pediatrics, the Society of General Internal Medicine, and the National Academy of

Medicine published statements and issued calls to action to address social determinants

of health (SDOH) at the individual, organizational, and policy levels.²¹ In 2021, ADA also

published a scientific review describing the associations between SDOH and diabetes risk

and outcomes.¹⁵ That review focused on socioeconomic status, health literacy, the food

environment and food insecurity, and neighborhood and physical environments, among

other topics.

Report to Congress

Socioeconomic position

Education, income, and occupation are strong predictors of the onset and progression of

type 2 diabetes. In the U.S., the age-adjusted prevalence of diagnosed type 2 diabetes is

75% higher for those with less than a high school education and 33% higher for those with

a high school education compared to those with more than a high school education. Having

a college education or more is associated with the lowest risk of type 2 diabetes. Compared

to those with high incomes, the prevalence of diabetes is 100% higher for those classified

as poor, 74% higher for those classified as near poor, and 40% higher for those classified

as middle income. Similarly, occupation as assessed by employment status (employed vs.

unemployed), job stability, job type, and working conditions shows graded associations with

diabetes prevalence and complications. Rural areas have higher age-adjusted prevalences

of type 2 diabetes than urban areas, and adults with diabetes in rural areas have had less

improvement in cardiovascular risk factors and have less access to preventive services than

their urban counterparts.23 Many of these factors have been associated with a higher risk of

progression to type 2 diabetes among individuals with prediabetes.

Health literacy

Health literacy is defined as the degree to which individuals can find, understand, and

use services to inform health-related decisions and actions.^{24, 25} Nearly half of individuals

living with diabetes have limited health literacy. Individuals with type 2 diabetes who are

beneficiaries of federally-funded programs, including Medicare and Medicaid, have higher

rates of limited health literacy, as do racial and ethnic minority groups disproportionately

affected by diabetes, and those with limited educational attainment.^{26, 27} Individuals with

limited health literacy have less awareness of evidence-based strategies to prevent diabetes

and, among those with diabetes, less awareness of and ability to implement evidence-

based strategies to manage diabetes and prevent its complications.²⁸ Limited health

literacy has been shown to independently contribute to type 2 diabetes incidence. Among

individuals with diabetes, it is also associated with worse diabetes control and higher

complication rates.

The food environment

Key dimensions of the food environment include food availability, accessibility, affordability,

and quality, as well as the marketing and commercial influences that drive consumption.

The food environment influences people’s food and beverage choices, diet quality, and

nutritional status. Marginalized communities are more likely to have poor access to healthy

foods but abundant access to energy-dense foods that are low in nutritional quality. They

are also more likely to be exposed to the marketing of such foods. Greater access to healthy

food outlets, higher availability of grocery stores and full-service restaurants, and lower

availability of convenience stores and fast-food restaurants are associated with lower rates

of type 2 diabetes.¹⁵

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Food insecurity

Food insecurity^{29, 30} (the limited or uncertain ability to reliably access safe and

nutritious food) is now recognized as a common and potent risk factor for developing type

2 diabetes and its complications and is a contributor to socioeconomic, racial, and ethnic

disparities in diabetes outcomes. Food insecurity compels individuals and families to

consume low-cost, carbohydrates- and energy-dense (high calorie) foods that increase the

risk of type 2 diabetes and make the clinical management of diabetes more challenging.

Food insecurity further forces individuals with diabetes to make difficult choices among

paying for food, housing, monitoring devices, medicines, and medical care. Finally,

populations with food insecurity may be predisposed to transmitting increased risk of type 2

diabetes across generations, in part through abnormal metabolic programming that occurs

in the fetus of the pregnant woman with food insecurity before birth.

The built environment

The neighborhoods and physical environments in which people live and work such as

buildings, streets, and open spaces have major impacts on their health. Neighborhood

walkability and access to green spaces are associated with physical activity and diabetes

outcomes.^31-34 Residential segregation by socioeconomic position, race, and ethnicity

produces patterns of unequal resource distribution that create and perpetuate health

inequities.

Housing instability refers to a spectrum of conditions that range from homelessness,

suffering evictions and frequent moves, having trouble paying rent, and living in crowded

conditions. Housing instability makes it difficult to attend to preventive services and

self-care, leading to worse prevention and control of diabetes and a higher likelihood

of complications.^35-37 In 2020, over 560,000 people in the U.S. were homeless. African

Americans accounted for 40% of people experiencing homelessness and Hispanics or

Latinos comprised 22% of the homeless population.³⁸ Among individuals with diabetes

seen in community health centers, over one-third reported housing instability. In the

Veterans Affairs (VA) health care system, veterans with diabetes experiencing homelessness

had significantly worse glucose control than those who were housed.³⁷

The ambient environment

Toxic environmental exposures are also associated with diabetes risk. Exposures can be

naturally occurring (for example, arsenic in water) or introduced into the environment

through human activity (for example, secondhand smoke, air pollution, industrial waste,

exposure to endocrine-disrupting chemicals).^39-41 Marginalized communities in the U.S.

are disproportionately exposed to environmental agents associated with diabetes.^42-44

Explanatory factors include closer proximity of underserved neighborhoods to pollution

sources, poor enforcement of regulations, and inadequate responses to community

Report to Congress

complaints. Industrial pollution of private wells is an important source of water

contamination in Native American Indian communities. Both food packaging from canned

foods and the release of chemicals from plastic packaging are important sources of

exposure to endocrine-disrupting chemicals linked to diabetes.⁴⁰

Rationale

The role of non-health federal agencies

To prevent and control diabetes, and to reduce health disparities, changes need to take

place in the social and environmental contexts in which U.S. residents live, learn, work,

and play. The fact that the social and environmental factors fuel the diabetes epidemic

make many patients and clinicians feel unsupported in their attempts to prevent and treat

diabetes. Implementing changes in federal agencies that are accountable for health care

concerns is not sufficient to address diabetes. Federal agencies that are considered to be

“non-health”-focused but have a role in shaping the social and environmental contexts

must also be involved. These include agencies responsible for domains as varied as food

and agriculture, education, housing, transportation, trade and commerce, and food and

drugs.

While most developed nations affirmatively address diabetes through trans-sectoral

governmental activities, the U.S. has not. The U.S. lacks adequate structures, policies, and

practices to coordinate strategic planning across health and non-health agencies. What

little work has been done to facilitate trans-agency action around diabetes prevention and

treatment has been of a pilot nature and lacks scale. There is an untapped opportunity to

better leverage the efforts of federal agencies, and increase coordination among them to

achieve the outcomes called for in the National Clinical Care Commission charter.

Policies and programs emanating from non-health-related federal agencies have

often been enacted without considering their impact on diabetes. To date, the federal

government has not implemented a “Health-in-All Policies” (HiAP) approach to ensure

coordination among non-health- and health-related federal agencies whose work is relevant

to diabetes. HiAP is an evidence-based collaborative approach that articulates health

considerations and integrates them into policies across sectors to improve the health

of all people and communities. HiAP can promote diabetes prevention and control by

influencing policies and practices of non-health agencies.

Health Impact Assessments (HIAs) are a widely accepted and evidence-based approach to

promote HiAP. HIAs use an array of data sources, analytic methods, and input to determine

the potential effects of proposed “non-health” policies, plans, programs, or projects on the

health of the population and the distribution of health effects across the population. HIAs

also provide recommendations on monitoring, managing, and mitigating adverse health

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effects. Despite recommendations from the Centers for Disease Control and Prevention

(CDC) that state and local governments adopt a HiAP approach, there has been no

targeted or sustained effort to advance a HiAP agenda or employ HIAs at the federal level,

either within or across federal agencies. There is no mandate that HIAs be considered

at the legislative stage or that federal agencies adopt a HiAP process at the rulemaking

stage. As a result, many non-health-related federal agencies may implement policies and

programs that are antithetical to the missions and objectives of health-related federal

agencies. The absence of a HiAP approach and the lack of interagency coordination

represent important and costly gaps in federal efforts to delay, prevent, and treat diabetes.

The federal government can play a larger role in preventing and controlling diabetes by

ensuring that non-health-related federal agencies conduct HIAs and that non-health- and

health-related federal agencies establish methodologies for HIAs; receive the resources

to generate HIAs; determine the mechanisms to adjudicate and implement HIAs; and

support, develop, and train the workforce needed to carry out HIAs.

Currently there is no federal entity that is charged with leading trans-agency efforts to better

prevent and control diabetes. Originally mandated by Public Law 93-354 ⁴⁵ and established

in 1975,⁴⁶ the Diabetes Mellitus Interagency Coordinating Committee (DMICC) facilitates

communication, collaboration, and coordination on diabetes-related projects among

federal agencies and helps to ensure that activities are not duplicated. DMICC is chaired by

the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and includes

select agencies from HHS, but only three non-HHS agencies and departments (the Veterans

Health Administration, the U.S. Department of Agriculture [USDA], and the U.S. Department

of Defense [DoD]).⁴⁶ While DMICC has fostered diabetes education and biomedical,

clinical, and translational research, it lacks the statutory authority to develop or implement a

national diabetes strategy or an action plan that leverages and coordinates the work of all

relevant health- and non-health-related federal departments and agencies.

Recommendation 3.1: The National Clinical Care Commission recommends the

creation of the Office of National Diabetes Policy (ONDP) to develop and implement

a national diabetes strategy that leverages and coordinates work across federal

agencies and departments to positively change the social and environmental

conditions that are promoting the type 2 diabetes epidemic. The National Clinical

Care Commission further recommends that the ONDP be established at a level above

the U.S. Department of Health and Human Services (HHS) and be provided with

funding to facilitate its effectiveness and accountability.

•

3.1a. The ONDP should include, but not be limited to, departments and

agencies outlined in the National Clinical Care Commission Report to

Congress, including the U.S. Departments of Agriculture, the U.S. Department

of Transportation, the U.S. Department of Education, the U.S. Department

Report to Congress

of Justice, the U.S. Department of Defense, the U.S. Department of Labor,

the U.S. Department of the Treasury, the Federal Trade Commission, the

Federal Communications Commission, the U.S. Department of Housing and

Urban Development, the Federal Bureau of Prisons, the U.S. Environmental

Protection Agency, the Bureau of Indian Education, the Bureau of Indian

Affairs, the U.S. Department of Veterans Affairs, and the U.S. Department of

Health and Human Services, among others.

•

3.1b. ONDP’s responsibilities should include: (1) overseeing the

implementation and monitoring of the National Clinical Care Commission’s

recommendations; (2) ensuring action, collaboration, and coordination

among federal agencies with respect to trans-agency approaches to delaying,

preventing, and controlling diabetes; (3) making recommendations to the

executive and legislative branches regarding actions they can take to delay,

prevent, and better treat diabetes; (4) advancing a health-in-all-policies

(HiAP) agenda with respect to diabetes; and (5) providing resources and

employing Health Impact Assessments (HIAs) for relevant policies across non-

health departments and agencies.

•

3.1c. HHS should also establish an entity within the Office of the Secretary of

HHS to (1) coordinate work across HHS to better prevent and treat diabetes;

and (2) serve in the ONDP to foster broad, trans-agency collaborative work

between HHS and non-HHS federal agencies aimed at positively changing

the social and environmental contexts that are driving the type 2 diabetes

epidemic.

Focus Area 2. Ensure Access to Health Care

Background

Access to health care refers to the degree to which individuals and groups can obtain

needed services from the health care system. In the U.S., health insurance coverage impacts

both individuals’ ability to gain access to care and their health outcomes. In people at risk

for or with diabetes, access to health care is critical to reducing the incidence of diabetes,

ensuring the early detection of diabetes, reducing the adverse health effects of diabetes,

and prolonging life.⁴⁷ As an example, adults with diabetes 65 years of age and older with

Medicare insurance have improved survival and fewer health disparities than adults with

diabetes less than 65 years of age without Medicare.⁴⁸

In the U.S., health insurance is pluralistic. Historically, its foundation was employer-based

coverage for working families. Most working-age adults obtained health insurance coverage

for themselves and their dependents as a benefit of employment. After 1965, Medicaid

and State Children’s Health Insurance Programs covered the poor, and Medicare covered

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virtually all Americans 65 years of age and older and younger people who were medically

disabled. This patchwork system left substantial numbers of Americans uninsured, including

employed workers whose employers did not provide health insurance coverage, the near

poor who earned too much to be eligible for Medicaid, and the poor who did not meet

Medicaid coverage requirements. Many, but not all, of these gaps in access to health

insurance were addressed by the Affordable Care Act (ACA).

The ACA made its intended impact on health insurance coverage among people with

diabetes. From 2009 to 2016, health insurance coverage for U.S. adults 18 to 64 years of

age with diabetes improved, with 770,000 more adults gaining health insurance.⁴⁹ Insurance

coverage improved for nearly all demographic subgroups with diabetes including men,

non-Hispanic whites, non-Hispanic Blacks, and Hispanics; those who were married; those

with less than as well as those with more than a high school education; and those with family

incomes less than $35,000. Coverage increased both among people treated with diabetes

medications and those with diabetes complications.⁴⁹ Insurance coverage for adults 26

to 64 years of age increased from 85% to 95% for those with diagnosed diabetes, 75% to

92% for those with undiagnosed diabetes. Among those with diabetes and low incomes,

insurance coverage leapt from 67% to 94%.⁵⁰ For those 65 years of age and older, coverage

remained stable at 99.5%, indicating the ongoing success of the Medicare program.⁴⁹

Analyses of health insurance coverage in the general population eight years after the ACA

confirmed that fewer Americans were uninsured and that coverage gaps in health insurance

were shorter.⁵¹ Nevertheless, in 2019, 31 million people or 9.5% of the population in the U.S.

were uninsured.⁵²

Health insurance coverage affects an individual’s ability to achieve optimal health outcomes.

Both poor diabetes control (as assessed by HbA1c >9%) and poor blood pressure control

(as assessed by blood pressure ≥140/90 mmHg) are more common among the uninsured

than among insured persons with diabetes.⁵³ Compared to insured people, uninsured

people with diabetes are more than twice as likely to have HbA1c >9%. Improvements in

health outcomes, including survival and reductions in health disparities, have also been

demonstrated for older adults with diabetes as a result of entering the Medicare program.⁴⁸

Rationale

Despite gains in insurance, income-related disparities in health care access and outcomes

have widened over time.⁵⁴ Compared to adults with higher incomes, U.S. adults with lower

incomes have reported having skipped 23% more needed doctor visits, tests, treatments,

or prescription medicines because of cost.⁵⁵ Nonadherence due to costs has been reported

in 20% to 40% of people with diabetes. For those with self-reported financial insecurity, the

nonadherence rate is even higher (60%).⁵⁶

Report to Congress

The COVID-19 pandemic has highlighted additional problems with access to care in the U.S.

During the early months of the pandemic, 21.9 million Americans lost their jobs or left the

workforce and 5.4 million of them became uninsured. Although some people who lost their

employer-sponsored health insurance were able to receive insurance through state-based

exchanges, the federal government initially declined to open its marketplace to offer special

enrollment periods and declined to account for income changes to provide subsidies.

These changes resulted in many newly unemployed individuals being unable to purchase

health insurance through the marketplace.

The COVID-19 pandemic has also highlighted problems with the Medicaid program.⁵⁷ To

date, 12 states have elected not to expand Medicaid, creating a “coverage gap” for adults

who have incomes above their states’ eligibility for Medicaid but below the level of income

making them eligible for tax credits to purchase health insurance through the marketplace.⁵⁸

In 2019, more than 2.2 million poor adults in the U.S. fell into the insurance coverage gap.⁵⁸

Ninety-seven percent of them lived in the Southern U.S.: 35% in Texas, 19% in Florida, 12%

in Georgia, and 10% in North Carolina.⁵⁸ Low-income individuals in the coverage gap are

more likely to be Black.^{58, 59}

Taken together, these findings highlight the importance of access to affordable health

care for people with or at risk of diabetes. Great strides have been made under ACA, but

important gaps remain. To address those gaps, access to employer-sponsored health

insurance coverage must be improved; the coverage and the affordability of individual

marketplace health insurance plans must be improved; and Medicaid must be expanded to

all 50 states.

Preventing and successfully treating diabetes is impossible if individuals do not have access

to comprehensive, high-quality, and affordable health care. Access to health care is essential

to health equity and is foundational to improving health outcomes for people with or at risk

for diabetes.

Recommendation 3.2: The National Clinical Care Commission recommends that

federal policies and programs be designed to ensure that all people at risk for and

with diabetes have access to comprehensive, high-quality, and affordable health

care and that no one at risk for or with diabetes who needs health care cannot get it

because of cost.

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Focus Area 3. Promote Health Equity in Diabetes

Rationale

Although addressing the social and environmental conditions, improving trans-agency

collaboration, and providing access to health care for peopleat risk for or with diabetes may

help prevent and control diabetes, attention must also be paid to the ways in which policies

and programs can be leveraged and coordinated to promote diabetes-related health

equity. Indeed, some federal policies and programs may inadvertently increase disparities.

The National Clinical Care Commission recommends that current and new federal programs

and policies affecting people with or at risk for diabetes be carefully reviewed to determine

their potential effects on health disparities.

Policies governing Diabetes Self-Management Training (DSMT) for Medicare beneficiaries

provide an example of federal policies unintentionally exacerbating health disparities.

Diabetes is primarily managed by individuals with diabetes, their families, and caregivers,

and exposure to DSMT can help them make better care decisions.⁶⁰ Unfortunately, because

federal policies present barriers to the availability and appropriate use of DSMT, disparities

based on race (lower for non-whites), health status (lower for those with comorbidities)⁶¹,

and in rural residence (limited access to accredited programs) have emerged. Indeed, 62%

of rural counties lack any DSMT programs.⁶²

On January 20, 2021, President Joe Biden issued an Executive Order on Advancing Racial

Equity and Support for Underserved Communities Through the Federal Government.⁶³

The National Clinical Care Commission supports this Presidential action and recommends

additional actions that are consistent with that Executive Order.

Recommendation 3.3: The National Clinical Care Commission recommends that

achieving health equity be a component of all federal policies and programs that

affect people at risk for or with diabetes. Specifically, the National Clinical Care

Commission recommends:

•

3.3a. Federal agencies consider and evaluate the impact on health disparities

of all new, all revised, and selected existing policies and programs that affect

diabetes prevention, diabetes, and the complications of diabetes.

•

3.3b. Federal agencies ensure the collection and use of data to assess the

impact of those policies and programs on health disparities and modify the

policies and/or programs as needed to reduce health disparities.

Report to Congress

Chapter 4: Population-Level Diabetes

Prevention and Control

Background

Programs directed by non-healthcare-related federal agencies and departments impact

diabetes in the U.S. Transportation, housing, agriculture, commerce, and other domains of

government affect diabetes risk and outcomes. This is true for those living with diabetes

who are at risk for developing complications; those with prediabetes who are at risk for

developing type 2 diabetes; and those in the general public, a proportion of whom are at

risk of developing prediabetes or diabetes over their lifetimes. Ensuring that policies and

practices of federal agencies and departments, many of which have a broad, population-

wide reach, do not contribute to the diabetes epidemic but instead are designed to prevent

and control diabetes, is a clinical and public health priority.

Historically, the clinical care of individuals with prediabetes and diabetes has involved a

combination of lifestyle counseling, patient self-management education, and therapeutics

(medications). However, a majority of Americans with prediabetes and diabetes have

inadequate resources and/or live in unsupportive environments with respect to diabetes.

This has undermined clinicians’ ability to prevent and manage diabetes and prevent its

complications.^{15, 64-66} In fact, research has shown that many clinicians report high levels of

frustration and clinical “burnout” when working in settings and systems that do not account

for the social, material, and psychological needs of patients with diabetes.⁶⁷ As a result,

the standard for high-quality, diabetes clinical care has evolved.⁶⁸ Contemporary diabetes

care now involves a comprehensive approach that combines the “traditional” model of care

(lifestyle counseling and medications) with an “integrated, patient-centered model” of care

that includes robust clinic-community linkages. These clinic-community linkages involve

referrals to programs, many of which are funded and/or directed by federal agencies, that

offer basic goods and services. Examples include programs that provide assistance with

nutrition, housing, and transportation, among others. The underlying rationale for this

comprehensive, integrated model is that connecting individuals to such resources will help

clinicians and patients better prevent and control diabetes and its complications.

Implementing integrated models of diabetes clinical care that extend beyond the walls of

the clinic and link patients to effective community resources and programs can improve

clinical outcomes of people with diabetes and reduce costs.^69-71 The American Diabetes

Association, the National Academy of Medicine (NAM), NIH, CDC, and the Centers for

Medicare & Medicaid Services (CMS) all endorse this integrated model of care, with the

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latter—through its Innovation Center—supporting the Accountable Health Communities

Program. However, to date, there has been no formal assessment of whether such federal

programs help prevent diabetes and/or its complications, or whether they meet the needs

of individuals with prediabetes or diabetes. Taken together, such individuals represent

nearly half of U.S. adults. Moreover, they represent roughly two-thirds of all U.S. adults

eligible to receive any form of public assistance.

The National Clinical Care Commission determined that it is critical to assess how federal

programs (including health and non-health-related programs) that influence the social

and environmental conditions experienced by individuals at risk for or with diabetes

and its complications can be designed, leveraged, and coordinated to enable such an

integrated model of care to achieve its objectives. Doing so will not only better support

clinicians caring for individuals at risk for or with diabetes, but also will increase the return

on investment of federal expenditures, by ensuring that the design of non-health-related

federal programs (for example, the Supplemental Nutrition Assistance Program [SNAP],

a USDA program) can enhance the efficacy of federal health care programs (for example,

Medicare, Medicaid, and HHS programs). Many of the recommendations made by the

National Clinical Care Commission Prevention—General Population Subcommittee are

intended to ensure that clinicians can provide high-quality, integrated care, and that their

patients can successfully prevent or self-manage diabetes.

One of the National Clinical Care Commission’s specific duties is to make recommendations

to improve federal education, awareness, and dissemination activities related to the

prevention and treatment of diabetes and its complications. Numerous studies have

demonstrated that the health literacy of a large segment of U.S. adults is inadequate. In

fact, nearly half of individuals living with diabetes have limited health literacy. Individuals

with diabetes who are beneficiaries of federally-funded programs such as Medicare

and Medicaid have even higher rates of limited health literacy, as do populations

disproportionately affected by type 2 diabetes, including certain racial and ethnic minority

subgroups and those with limited education.^{26, 27} Individuals with limited health literacy have

less awareness of evidence-based strategies to prevent diabetes and, among those with

diabetes, less awareness of evidence-based strategies to successfully manage diabetes

and prevent its complications. As one example, limited health literacy has been found to be

the strongest independent predictor of the consumption of sugar-sweetened beverages,

driver of type 2 diabetes risk.²⁸ Comparing those with the lowest to the highest health

literacy demonstrates a difference in intake of 240 calories per day from sugar-sweetened

beverages—equivalent to one daily 20 oz of a sugar-sweetened soda. In addition, studies

have shown that clinicians often struggle when attempting to prevent and manage

diabetes for their patients with limited health literacy and report that their patients need

additional community-level support to enable effective clinical care.⁷² A number of federal

agencies support and direct programs and engage in activities that can influence public

Report to Congress

awareness related to diabetes prevention and control. These include CDC, NIH, the Food

and Drug Administration (FDA), USDA, and FTC, among others. Many of the Commission’s

recommendations included in this chapter relate to the coordination and leveraging of

the work of these federal agencies and departments to promote education and greater

awareness of diabetes prevention and care.

Recommendations

Focus Area 1. Modernize USDA’s Supplemental Nutrition

Assistance Program

Background and Rationale

Food insecurity and insufficiency increase the risk of developing diabetes, contribute to

difficulty^{29, 73, 74} managing diabetes,⁷⁵ and lead to costly and disabling complications.⁷⁵

The relationship between food insecurity³⁰ and diabetes operates through at least four

mechanisms: poor dietary quality, cycles of bingeing and fasting, stress pathways, and

competing demands leading to poor self-management of diabetes. The USDA SNAP

program provides benefits to supplement the food budget of income-eligible individuals

and households (approximately 40 million people per year) so they can purchase food and

move towards self-sufficiency.^{76, 77} SNAP is a valuable program for reducing food insecurity,

but its impacts on diet quality⁷⁸ and diabetes risk have not been optimized. Healthier,

nutrient-rich foods often cost more than foods that are energy dense (high calorie) and have

lower nutritional value. SNAP has been less successful in providing “nutrition security,” a

state that encompasses both food security and nutrient content that promotes health.^{79, 80}

SNAP benefit recipients often have to stretch their benefit allotments by purchasing lower-

cost, less healthy food items,⁸¹sacrificing nutrition quality and elevating their risk for obesity,

diabetes, or diabetes complications, as well as other nutrition-related conditions.

There is substantial overlap between eligibility for SNAP and eligibility for Medicaid and

Medicare. In part because of the higher rates of food insecurity among people with lower

incomes and in older age groups, diabetes and prediabetes are common in Medicaid

and Medicare beneficiaries.^82-84 Efforts to prevent diabetes and diabetes complications in

SNAP beneficiaries will provide health benefits for these populations, and yield savings for

Medicare and Medicaid.⁸⁵

The National Clinical Care Commission has identified four domains of the SNAP program

that need to be addressed to ensure that the vital nutrition assistance that it provides not

only does not contribute to diabetes but also prevents diabetes and/or its complications.

These include (1) improving dietary quality; (2) expanding individual education efforts for

diabetes prevention and catalyzing systems and environmental change to support dietary

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behavior change; (3) updating the benefit amount; and (4) expanding awareness and

accessibility of the program. The USDA has begun to address some of these domains;

enhancing these efforts would help reduce the burden of diabetes and its complications.

Improving dietary quality

SNAP participants currently consume fewer fruits and vegetables and more added sugars

than recommended in diets that can prevent and manage diabetes.^{79, 86} Through the Farm

Bill, USDA funded a series of healthy food incentive pilot programs, whose intentions are to

help SNAP participants purchase healthier foods (often more costly), especially fruits and

vegetables. These incentive pilots are currently distributed via small grants administered

by USDA.⁸⁷ Rigorous evaluations of these initiatives have consistently shown benefits in

improving dietary quality.^{88, 89} The Gus Schumacher Nutrition Incentive Program (GusNIP),

formerly known as the Food Insecurity Nutrition Incentives (FINI) Program, is one such

promising USDA program that could benefit all SNAP participants and help prevent and

control diabetes if implemented program-wide. Additionally, sugar-sweetened beverages

are one of the main sources of added sugars in U.S. diets, and especially among SNAP

recipients.⁸⁶ Sugar-sweetened beverages contain excess calories, have limited to no

nutritional value, ⁹⁰ and contribute to type 2 diabetes and diabetes complications. To

help ensure that SNAP benefits are used to assist in achieving nutrition security and do

not contribute to diabetes or diabetes complications, many experts have recommended

removing sugar-sweetened beverages as an allowable SNAP purchase because of the

health and economic benefits that would accrue.^91-94 It has been estimated that, over a ten-

year period, eliminating the use of SNAP subsidies to purchase sugar-sweetened beverages

would prevent 240,000 cases of type 2 diabetes among SNAP beneficiaries.⁹¹

Expanding educational efforts

To achieve maximum benefit from these healthy incentives and purchase exclusions, greater

outreach to and education of SNAP participants would be required. SNAP-Education (SNAP-

Ed)⁹⁵ is a promising program that could be amplified to help SNAP participants better

achieve food and nutrition security and reduce nutrition-related diabetes risks.

Increasing the benefit

SNAP benefit allotments are determined based on the USDA Thrifty Food Plan (TFP).

Many analyses have found that the food procurement and preparation requirements and

expectations associated with the TFP are unrealistic and inadequate for providing sufficient

funds for most SNAP participants.^{96, 97} In addition, there had been a lag in updating the TFP

beyond the required cost-of-living adjustments, making it an even more inadequate basis

for calculating SNAP benefit allotments.⁹⁸ In early 2021, the USDA announced that SNAP

benefits were inadequate for most participants and began a data-driven reevaluation of

the TFP to determine the costs associated with a basic healthy diet and to ensure nutrition

Report to Congress

security. On August 16, 2021, USDA released the results of this reevaluation, which

determined that the cost of a nutritious, practical, cost-effective diet is 21% higher than the

benefit determined based on the current TFP. Based on the findings, in FY 2022 (beginning

on October 1, 2021) the average SNAP benefit—excluding additional funds provided as

part of the COVID-19 pandemic relief—will increase by $36.24 per person, per month (an

increase of more than 25%).⁹⁹

Expanding awareness and accessibility

Challenges associated with complexity, technology, numeracy, and language proficiency,

have kept many SNAP-eligible individuals or families from receiving SNAP benefits and have

resulted in disparities in receipt of SNAP benefits.^{100, 101} State-level innovation is needed to

overcome these barriers at a local level. These efforts should include but not be limited to

streamlining the application process, increasing public awareness of the benefit and how

to access SNAP in various languages, increasing the number of sites that accept SNAP, and

helping stores in rural areas and “food deserts” meet minimum stocking requirements.

Recommendation 4.1: The National Clinical Care Commission recommends that

the USDA SNAP program be enhanced to both reduce food insecurity and improve

nutrition sufficiency, both of which will help prevent type 2 diabetes and diabetes

complications.

•

4.1a. Implement SNAP-wide fruits and vegetables incentives demonstrated

to be effective by the Gus Schumacher Nutrition Incentive Program (GusNIP)

for all beneficiaries, by providing at least a 30% incentive on the purchase of

fruits and vegetables to improve dietary quality.

•

4.1b. Eliminate sugar-sweetened beverages from allowable SNAP purchases.

•

4.1c. Improve and expand SNAP-Education to provide diabetes and nutrition

education and awareness programs for beneficiaries to increase fruit and

vegetable consumption, reduce added sugars consumption (especially sugar-

sweetened beverages), and increase media/marketing literacy, as well as

increase its support for policy, systems, and environmental approaches to

improve dietary quality.

•

4.1d. Incentivize testing and implementation of innovative state-level policies,

practices, and programs to enhance the access to and receipt of SNAP

benefits by eligible individuals and households, and to reduce geographic,

racial, ethnic, and linguistic disparities in SNAP enrollment and retention.

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•

4.1e. Sustain efforts to ensure that SNAP benefit allotments are adequate

to allow for both food and nutrition security to help prevent and manage

diabetes among beneficiaries and implement a process to regularly assess

and update the adequacy of SNAP benefits with respect to lowering diabetes

risk and managing diabetes.

Focus Area 2. Improve Nutrition for Children Through USDA non-

SNAP Nutrition Assistance Programs and Related Agency Efforts

Background and Rationale

Type 2 diabetes was once considered a disease of older adults. Unfortunately, the incidence

of type 2 diabetes is now rapidly increasing in children and adolescents, especially children

from low-income families and children of color.¹⁰² Rates of gestational diabetes (diabetes

during pregnancy) also are on the rise.¹⁰³ USDA, with its $146B annual budget, provides

nutritional assistance through programs besides SNAP, with a focus on nutrition assistance

during pregnancy and early childhood. These programs not only reduce food insecurity

but have the potential to prevent and control type 2 diabetes, if redesigned with those

objectives in mind.

The Special Supplemental Nutrition Program for Women, Infants, and Children

(WIC) serves approximately 7 million participants every month. Since revising its food

package in 2009 to restrict purchases of unhealthy foods, WIC has been shown to reduce

excess weight gain in pregnant and post-partum women,¹⁰⁴ improve birth weight of

infants,¹⁰⁵ and reduce childhood obesity.¹⁰⁶ All of these lower the risk of type 2 diabetes.

However, this prescriptive food package is at risk of being weakened. Furthermore,

inadequate technology infrastructure has limited the efficacy of WIC with respect to

diabetes prevention. WIC providers have made technological advances by implementing

electronic-benefit transfer (EBT), or e-WIC transactions nationwide. However, the WIC

certification process continues to pose challenges for applicants and participants. These

challenges could be addressed by allowing remote certification; integrating new projects

into WIC sites’ computer networks; and enabling innovations such as web-based participant

portals, prescreening tools, text-messaging features, and additional transaction models such

as online purchasing mobile payments. In addition, as part of its mission to safeguard the

health of low-income women, infants, and children, WIC plays a critical role in promoting

breastfeeding as the optimal infant feeding choice and has demonstrated effectiveness¹⁰⁷

in increasing breastfeeding rates^{108, 109} among women who utilize WIC services.^110-112

However, WIC’s breastfeeding support services, such as those provided through the WIC

Breastfeeding Peer Counselor Program, do not receive adequate funding to offer those

services at all WIC sites.

Report to Congress

The National School Lunch and Breakfast Programs serve approximately 30 million

children each day. Since the inception of the Healthy, Hunger-Free Kids Act (HHFK) in 2010,

the incidence of obesity among low-income children in the program declined by 47%.¹¹³

However, some schools face challenges meeting the new nutrition standards, including

costs and availability of foods, inadequate staff training, equipment, and infrastructure. As

a result, HHFK nutritional standards are continually at risk of being weakened. In addition,

many public schools across the country allow or even promote the sale of unhealthy

(calorically dense and nutrient-poor) foods, including sugar-sweetened beverages, on

campus, in vending machines, cafeterias, and canteens. Given that school meals contribute

to more than half of the daily caloric intake of U.S. children who participate in the food

programs, these practices increase children’s risk of obesity and type 2 diabetes. Notably,

those states that have more stringent laws regarding the sale of unhealthy food on school

campuses have been shown to have significantly lower rates of obesity among youth.¹¹⁴

The Summer Meal Programs: Summer Food Service Program and Seamless

Summer Option

The Summer Food Service Program is a federally-funded, state-administered program that

reimburses providers (schools, local government agencies, faith-based and other non-

profit community organizations with the ability to manage a food service program) who

serve free, healthy meals to children and teens at approved meal sites in low-income areas

during the summer when school is not in session. In addition, schools that participate in the

National School Lunch or School Breakfast Program are eligible to apply for the Seamless

Summer Option, which makes it easier for schools to feed children during traditional

summer vacation periods. Once the Seamless Summer Option is approved by the state

agency, schools can serve meals free of charge to children, including teenagers through

age 18, under the school meal program rules. However, many children who participate

in school meal programs (that is, National School Lunch and Breakfast Programs) do not

receive healthy meals during the summer. In the summer of 2019, the Summer Food

Service Program and the Seamless Summer Option through the National School Lunch

and Breakfast Programs reached only 1 in 7 children (13%) who received free or reduced-

price lunch during the 2018-2019 school year.¹¹⁵ During the COVID-19 pandemic, USDA

expanded the summer meal programs so that program operators could continue serving

free meals to all children. The federal government’s efforts to expand these programs

provided food and nutrition for children when families faced critical food shortages. The

role these programs played during the COVID-19 pandemic highlights how important they

are for children who will continue to face food insecurity after the pandemic.

The Fresh Fruit and Vegetable Program provides funding to participating schools so

that they can provide children with a wide variety of fresh fruits and vegetables that can

help prevent type 2 diabetes. The program’s budget, however, is only $183 million (FY 2021

Enacted), or 0.1% of USDA’s annual budget. Studies have shown that the program is able

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to increase the fresh fruit and vegetable intake of participating children by 1/3 cup per day

without increasing calorie intake.¹¹⁶ There is a much greater demand for this program than

available funds allow.

Recommendation 4.2: The National Clinical Care Commission recommends that

USDA non-SNAP feeding programs be better leveraged to prevent type 2 diabetes in

women, children, and adolescents by (1) enhancing Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC); (2) further harnessing the National

School Lunch and Breakfast Programs to improve dietary quality; and (3) expanding

the Summer Nutrition Programs and the Fresh Fruit and Vegetable Program.

•

4.2a. Further strengthen the WIC program by sustaining the evidence-based,

prescriptive WIC food package; expand funding for breastfeeding peer

counseling services (see also Recommendation 4.7); invest in improvements

to information systems and technology to enable greater access and service

for WIC participants.

•

4.2b. Maintain the nutrition standards found to be salutary in the Healthy

Hunger-Free Kids Act (HHFKA) and provide adequate funding for schools

to (a) purchase, prepare, and serve healthy, quality foods and beverages

for school meals and snacks to meet the HHFKA nutrition standards and

(b) deliver training and technical assistance to support maintenance and

attainment of HHFKA nutrition standards, and skills to run a program to

effectively prevent type 2 diabetes.

•

4.2c. In collaboration with the U.S. Department of Education, the U.S.

Department of the Interior, the U.S. Environmental Protection Agency, USDA

should ensure that all students in public and tribal schools have reliable

access to safe, appealing, and free drinking water. This could be accomplished

through a combination of federal incentives and possibly tying receipt of

funding for school-based food programs in the future.

•

4.2d. Prohibit the sale of calorically dense and nutrient-poor foods, including

sugar-sweetened beverages, on public school campuses; and employ an

incentive program to enable schools to cover essential costs such as those for

physical activity/athletic programs previously underwritten by the sale of such

unhealthy foods and beverages. Receipt of federal funds for school-based

food programs should be tied to implementation of such restrictions.

•

4.2e. Strengthen, increase funding for, and improve access to and

participation in summer feeding programs, including partnerships and

collaboration between public and private sectors, to promote innovation

in rural areas and other high-risk areas where participation has been low.

Funding for these programs should be increased to enable scaling to meet

population needs.

Report to Congress

Patient Testimonial

-- Joseph Angelo, a 58-year-old man with type 2 diabetes

since 2014 who currently manages his condition using oral

medications and an injectable diabetes medication. Mr.

Angelo lost his job and was part of a pilot program that

provided incentives to purchase fresh fruits and vegetables.

“IT’S LIKE THE DAY AFTER CHRISTMAS

Having diabetes myself, I’ve been taught by my doctors and

nurses about the things I should and shouldn’t eat to help

me manage my diabetes. This education has been great.

But when I actually try to follow their advice, I’m hit with the

sticker shock of reality. A lot of folks on a fixed income struggle with how to make decisions

about what foods to buy and eat with the limited resources we have. Mostly, we’re trying to

think of what we can get the most meals out of. Fresh fruits and vegetables have a higher

mark-up compared to processed foods or junk food or soda, so a lot of people have little

choice but to eat unhealthier foods.

For me this SNAP incentive will absolutely help me buy and eat healthier foods, as opposed

to the cheaper, processed foods that have empty calories and are more immediately

filling. Having such a program can make the sticker shock of reality go away, motivating me

to buy and eat the kinds of food that can keep me healthy. It makes making the right choice

become the easier choice for me.

Stretching out SNAP dollars this way means that buying nectarines, peaches, broccoli or

carrots is a decision more of us will make, because it has better value both financially and

health-wise. The SNAP fruits and vegetable incentive will stretch my dollar further. Without

it, the high cost of fruits and vegetables has made it hard for me to even look at them; now I

really can consider buying them.

It feels like the day after [Christmas], when the prices go down. All those fruits and

vegetables that I had wanted to buy the day before but couldn’t because they were so

expensive, now (all of a sudden) they’re attainable!”

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Focus Area 3. Modify USDA Programs That Support Farmers to

Make the U.S. Food Supply Healthier

Background and Rationale

The Farm Bill ($86 billion) provides a great opportunity to link the aims of supporting

farmers and achieving food security with public health and health care goals related to

diabetes. The Farm Bill is a powerful, underutilized tool to potentially prevent and control

diabetes, curb health care spending, and reduce disparities. Below are three USDA

programs that could be substantially enhanced to help reduce the risk for diabetes and

diabetes complications in the U.S. population.

The Specialty Crop Block Grant Program aims to enhance the competitiveness of

specialty crops, which are defined as “fruits, vegetables, tree nuts, dried fruits, horticulture,

and nursery crops.”¹¹⁷ The associated budget was $85 million, or 0.1% of the Farm Bill

budget.

The Specialty Crop Research Initiative works to address the critical needs of

sustaining the specialty crop industry including conventional and organic food production

systems. This includes efforts to improve production efficiency, handling and processing,

productivity, and profitability of specialty crops over the long term. The associated budget

was also $85 million, or 0.1% of the Farm Bill budget.

The Healthy Food Financing Initiative (HFFI) provides grants and loans to improve

access to fresh and healthy foods by financing grocery stores, farmers’ markets, food hubs,

and co-ops in urban and rural areas. The grants and loans provided through the initiative

help food retailers overcome the higher costs and initial barriers associated with providing

fresh and healthy food options for individuals and families who live in low-access areas.

Evidence¹¹⁸ shows that HFFI-financed programs increase food security and reduce intake

of added sugars and decrease the percentage of daily calories from solid fats, alcoholic

beverages, and added sugars. The associated budget was ~$25 million, or 0.03% of the

Farm Bill budget.

Recommendation 4.3: The National Clinical Care Commission recommends that

resources be provided to USDA to create an environmentally friendly and sustainable

U.S. food system promoting the production, supply, and accessibility of foods such as

“specialty crops” (fresh fruits, dried fruits, vegetables, tree nuts) that will attenuate the

risk for type 2 diabetes and the complications of diabetes.

•

4.3a. Significantly expand and increase funding for the USDA Specialty Crop

Block Grants to support the safe production and distribution of food and drive

demand through education for specialty crops to increase dietary diversity as

an aid to help people prevent and/or control diabetes.

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•

4.3b. Significantly increase funding for the USDA Specialty Crop Research

Initiative grants to improve specialty crop production efficiency, handling and

processing, productivity, and profitability (including specialty crop policy and

marketing) over the long term in a sustainable manner.

•

4.3c. Significantly expand and increase funding for the USDA evidence-based

Healthy Food Financing Initiative, a federal effort to improve food access and

health in low-income, underserved communities and communities of color

in urban and rural areas that supports farmers and healthy food retailers to

improve access to nutritious, affordable, and fresh food.

•

4.3d. Funding and expansion should be implemented by 2030 to achieve

population-wide benefits.

Focus Area 4. Encourage the Consumption of Water Over Sugar-

Sweetened Beverages

Background and Rationale

When water replaces caloric beverages, consuming water is associated with improved

glycemic (blood sugar) control.¹¹⁹ Tap water is the preferred source of drinking water, but in

areas where tap water is known to be contaminated, filtered or bottled water is acceptable.

Many regions of the U.S. face persistent challenges in providing clean tap water to their

populations because of contamination of water sources or the systems that deliver water to

homes, schools, and workplaces (see Focus Area 4.8).¹²⁰

Replacing sugar-sweetened beverages with water in institutions such as schools and

delivering clean water to homes to replace sugar-sweetened beverages have been shown

to be particularly promising^{121, 122} in reducing obesity and type 2 diabetes risk. Modelling

studies have shown that consuming water instead of sugar-sweetened beverages

could significantly reduce the national prevalence of obesity and diabetes, by lowering

caloric intake and preventing metabolic side effects of consuming liquid sugar.¹²³ To

enhance diabetes prevention and control, strategies to increase clean water availability

and consumption should be coupled with strategies that reduce sugar-sweetened

beverage availability, with the overall goal of promoting water consumption and reducing

consumption of added sugars.

Sugar-sweetened beverages represent the largest single source of added sugar in average

U.S. diets (30-40%) and comprise between 50% and 90% of the recommended daily limit

of added sugars.¹²⁴ However, many Americans consume well above the average amount,

placing them at especially high risk for type 2 diabetes. Nearly two-thirds of U.S. children

and youth consume at least one sugar-sweetened beverage per day, one in five consume

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Report to Congress on Leveraging Federal Programs to Prevent and Control Diabetes and Its Complications (2021) - page 1