2016 Presidential Address: Diabetes at 212° Confronting...

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2016 Presidential Address: Diabetes at 212°dConfronting the Invisible Disease Diabetes Care 2016;39:16571663 | DOI: 10.2337/dc16-1558 This address was delivered by Desmond Schatz, MD, President, Medicine & Sci- ence, of the American Diabetes Association (ADA), at the Associations 76th Sci- entic Sessions in New Orleans, LA, on 12 June 2016. Dr. Schatz is Professor and Associate Chairman of Pediatrics, Medical Director of the University of Florida Diabetes Institute, and Director of the Clinical Research Center at the University of Florida, Gainesville, FL. A physician-scientist, he has been involved in type 1 di- abetes research since the mid-1980s and has published over 300 articles and book chapters. Dr. Schatzs research focuses on the prediction, natural history, genetics, immunopathogenesis, and prevention of type 1 diabetes, as well as the treatment of children and adolescents with type 1 diabetes. He is the principal investigator on several National Institutes of Health, JDRF, and other competitively funded grants. Dr. Schatz earned his medical degree from the University of the Witwa- tersrand School of Medicine in Johannesburg, South Africa, and completed his residency and fellowship at the University of Florida. He has been an ADA volun- teer for over 30 years and has served on the Professional Practice Committee (twice), Scientic Sessions Meeting Planning Committee, Publications Policy Com- mittee (Chair), Government Relations Committee, Youth Strategies Committee, and Board of Directors. A board-certied pediatric endocrinologist, Dr. Schatz is the 2016 recipient of the Banting Medal for Leadership and Service from the ADA for his outstanding commitment and contributions to the Association. 212° is not just a number. It is the boiling point of water. I think of 212°F as the point where water is no longer still but erupts with urgency. It is a point of transformation where matter dramatically changes form as the boiling water turns to steam. Steam can power a generator and create energy, and energy powers movement. Diabetes is an epidemic that is spiraling out of control across the U.S. and around the world, and yet it remains largely invisible. I challenge everyone today to consider how together we can create a scalding sense of urgencydthe type that is capable of achieving transformational changedto transition diabetes from an invisible disease to a highly visible crisis that threatens the very fabric and resources of our society. That would be diabetes at 212°! In a preview to the 2015 American Diabetes Associations (ADA) Scientic Ses- sions in Boston, MAdthe 75th anniversary of the AssociationdI was startled by the headline in the Timmerman Report, Cancer Is Hot, Diabetes Is Not: Watch for Drug Safety and Cost Debates at ADA(1): The Internet was crackling this week with stories of progress against a disease that kills lots of people, and costs society billions of dollars in lost productivity. That was cancer. Dont expect such hopeful scienti c narratives this weekend, as physicians gather in Boston to discuss another common scourgeddiabetes. Compared with innovation in cancer, diabetes is dullsville. Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL Corresponding author: Desmond Schatz, schatda@ peds.u.edu. For a webcast of the 2016 Presidential Address, please go to professional.diabetes.org/2016PresMS. © 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for prot, and the work is not altered. More infor- mation is available at http://www.diabetesjournals .org/content/license. Desmond Schatz Diabetes Care Volume 39, October 2016 1657 PRESIDENTIAL ADDRESS

Transcript of 2016 Presidential Address: Diabetes at 212° Confronting...

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2016 Presidential Address:Diabetes at 212°dConfrontingthe Invisible DiseaseDiabetes Care 2016;39:1657–1663 | DOI: 10.2337/dc16-1558

This address was delivered by Desmond Schatz, MD, President, Medicine & Sci-ence, of the American Diabetes Association (ADA), at the Association’s 76th Sci-entific Sessions in New Orleans, LA, on 12 June 2016. Dr. Schatz is Professor andAssociate Chairman of Pediatrics, Medical Director of the University of FloridaDiabetes Institute, and Director of the Clinical Research Center at the University ofFlorida, Gainesville, FL. A physician-scientist, he has been involved in type 1 di-abetes research since the mid-1980s and has published over 300 articles and bookchapters. Dr. Schatz’s research focuses on the prediction, natural history, genetics,immunopathogenesis, and prevention of type 1 diabetes, as well as the treatmentof children and adolescents with type 1 diabetes. He is the principal investigatoron several National Institutes of Health, JDRF, and other competitively fundedgrants. Dr. Schatz earned his medical degree from the University of the Witwa-tersrand School of Medicine in Johannesburg, South Africa, and completed hisresidency and fellowship at the University of Florida. He has been an ADA volun-teer for over 30 years and has served on the Professional Practice Committee(twice), Scientific Sessions Meeting Planning Committee, Publications Policy Com-mittee (Chair), Government Relations Committee, Youth Strategies Committee,and Board of Directors. A board-certified pediatric endocrinologist, Dr. Schatz isthe 2016 recipient of the Banting Medal for Leadership and Service from the ADAfor his outstanding commitment and contributions to the Association.

212° is not just a number. It is the boiling point of water. I think of 212°F as the pointwhere water is no longer still but erupts with urgency. It is a point of transformationwhere matter dramatically changes form as the boiling water turns to steam. Steamcan power a generator and create energy, and energy powers movement.Diabetes is an epidemic that is spiraling out of control across the U.S. and around

theworld, and yet it remains largely invisible. I challenge everyone today to considerhow together we can create a scalding sense of urgencydthe type that is capable ofachieving transformational changedto transition diabetes from an invisible diseaseto a highly visible crisis that threatens the very fabric and resources of our society.That would be diabetes at 212°!In a preview to the 2015 American Diabetes Association’s (ADA) Scientific Ses-

sions in Boston, MAdthe 75th anniversary of the AssociationdI was startled by theheadline in the Timmerman Report, “Cancer Is Hot, Diabetes Is Not: Watch for DrugSafety and Cost Debates at ADA” (1):

The Internet was crackling this week with stories of progress against a disease that kills lots ofpeople, andcosts societybillionsofdollars in lostproductivity.Thatwascancer.Don’texpectsuchhopeful scientific narratives this weekend, as physicians gather in Boston to discuss anothercommon scourgeddiabetes. Compared with innovation in cancer, diabetes is dullsville.

Department of Pediatrics, College of Medicine,University of Florida, Gainesville, FL

Corresponding author: Desmond Schatz, [email protected].

For a webcast of the 2016 Presidential Address,pleasego toprofessional.diabetes.org/2016PresMS.

© 2016 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered. More infor-mation is available at http://www.diabetesjournals.org/content/license.

Desmond Schatz

Diabetes Care Volume 39, October 2016 1657

PRESID

ENTIA

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Dullsville? Diabetes should be as hot atopic as any that exists in health care andthat includes the Zika virus. This disparitypartly influenced this presentation.Almost 4 years ago, I was invited to

speak at a diabetes outreach eventbefore 100 enthusiastic children withtype 1 diabetes and their parents. Iwas asked to talk about progress towardour understanding of the causes and theprospects for a cure. As I invariably do, Iencouraged everyone in the audience tointerrupt me anytime and ask any ques-tions. About 10 min into the talk, littleKatie’s hand shot up. Katie was 9 yearsold but wise beyond her years. She cutto the chase. Diagnosed with type 1 di-abetes at the age of 14 months, she hadlived with the disease for 8 years andwas tired of having it. After an estimated20,000 finger sticks, 8,000 injections,and 450 pump site changes, it is easyto understand Katie’s frustration. Shewanted to know when she would becureddafter all, AIDS, hepatitis C, andsome forms of childhood cancer couldbe cured! Were we not smart enoughor working hard enough? Were we notspending enough money on it? Why didso few people really understand whatshe went through each and every day?In essence, Katie was asking, where wasour sense of urgency?I paused and reflected, and as I strug-

gled to answer, I realized that we thinkwe know a lot about diabetes, but thereis a lot more we do not know. Despitethe remarkable amount of intellect andknowledge at the Scientific Sessions, weunfortunately know less than we think.To support the points made, Video 1

(professional.diabetes.org/NoMoreHiding)showcases one patient’s perspective anddaily burden of managing diabetes thatmay not be understood or clearly visibleto those around.The lack of visibility also extends to

the patient-doctor relationship. Figure1, strikingly similar to the World Diabe-tes Day symbol, signifies the unity of theglobal diabetes community, with theexception of the tiny break in the bluecircle representing the amount of timethat a patient with diabetes spends dis-cussing his or her condition with a med-ical professional in a year. The breakaccounts for less than 0.03% of theareadless than 150 min out of the525,600 min in a year. The reality is thathealth care providers are largely invisible

as the patients manage a very complexdisease on their own.

How many patients with type 2 dia-betes choose to be invisible largely be-cause of their own sense of failure andthe frustration they confront during anoffice visit, knowing their blood glucoseis still poorly controlled, their weight hasnot changed, and little or no effort wasmade to diet or exercise? Most patientsstop taking their medications as pre-scribed after 6–12 months, losing mostof the clinical benefit. Blaming and stigmadevelop, and then so does a profoundsense of worry and fear among manypatientsdpatients who have seen rela-tives suffer frightening consequences ofadvanced disease, including prematuremortality. It is easy to criticize and cajolethese patients in hopes of improving theirclinical profiles. But how often do healthcare providers actually take time to hear orlearn about their burden and the real rea-sons why they cannot seem to controltheir diabetes?

I ask, do we have a sense of urgencyto resolve their burdens and questionsrather than constantly doling out thesame advice with the same expectationsand achieving the same lackluster results?

Unfortunately, diabetes remains invis-ible even to our own medical communityas the diagnosis of both type 1 and type 2diabetes does not come early enough oris still missed. A recent headline read,“Mom plans funeral for daughter daysafter being diagnosed with diabetes”(2). A Tennessee mother took a vacationto spend spring break with her children.When her 11-year-old daughter beganhaving muscle spasms, she took her to

the doctor where she was prescribedsome medications and told to drinkplenty of fluids. Two days later, themother found her daughter unresponsiveand rushed her to the hospital whereshe was diagnosed as having diabetic ke-toacidosis with blood glucose measuring1,600mg/dL. Instead of a fun-filled springbreak, this mother lived every parent’snightmare. She planned a funeral forher precious child days after her daugh-ter’s diagnosis of diabetes.

Sadly, this is not an aberration.Deaths from missed diagnosis oftype 1 diabetes still occur. In a reviewof their data from Toronto, Canada, Buiet al. (3) showed that almost 20% ofchildren present with diabetic ketoaci-dosis. In children aged ,3 years, thisnumber rises to 40%, and many hadhad a clinic visit the week before presen-tation. For type 2 diabetes, consistent andtimely diagnosis remains elusive, withstudies revealing on average a period ofmore than 6 years from actual onset todiagnosis (4).

I ask, do you have a sense of urgencyto remove the invisibility of this diseaseamong our colleagues in the medicalcommunity to stop the senseless deathsfrom diabetic ketoacidosis?

Diabetes is like a wildfire ragingthrough this country and across the globe,but is anyone really paying attention?Every year, we hear similar statistics.Yet the disease and related skyrocketinghealth care costs seem invisible to thegovernments of the world.

The general public, too, remains inthe dark about diabetes. A recent HarrisPoll revealed that cancer and heart diseaseare perceived as far more serious than di-abetes. The vastmajority of the individualspolled feel that people with diabetes havethemselves to blame and know very littleabout the disease (5). Consequently, manyare far more likely to know their bloodpressure and cholesterol than their bloodglucose. This must change!

Diabetes is the epidemic of the 21stcentury. The eye-opening statistics onthe prevalence of diabetes are not lack-ing; however, consider these numbersin relation to all the recent media re-ports about the Zika virus epidemicand the urgent concerns and visibilityit has and then realize how downplayeddiabetes is by comparison.

In the U.S., in the past 30 years, theincidence of diabetes has skyrocketed

Figure 1—The tiny break in the blue circlerepresents ,0.03% of the time a patientwith diabetes actually spends with amedicalprofessional in a year (22).

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sixfold such that 30 million Americansare now affected. Ninety percent havetype 2 diabetes, and almost 8 million donot even know that they have the dis-ease. Further, only 10% of the 86 millionpeople with prediabetes are aware oftheir condition.Worldwide, the number has quadru-

pled since 1980; 415 million people arenow affected. The disease is invisible tothe 46% of adults who are undiagnosedand do not know they have the disease. Apatient dies every 6 s from diabetes andits consequences. It is projected that bythe year 2040, 1 in 10 peoplewill be livingwith this disease, with health care expen-ditures over the next two decades ex-pected to exceed $7 trillion. Already inthe U.S., people with diabetes accountfor up to 1 in 5 health care dollars (6,7).I ask, do we not have the sense of

urgency to convince the public and ourgovernments that there is a wildfire rag-ing? Do we not have the wherewithal tomount the type of activism and advo-cacy for diabetes as has been done sowell for HIV/AIDS?A perfect storm is brewing. The prev-

alence of diabetes is climbing at a mete-oric rate, and of those living with thedisease, few are meeting targets. Weknow the association between controland complications. We also know theassociation between complications andcosts, both human and financial.The minority of patients with type 1

diabetes, both children and adults, areachieving targets. Recent data from theT1D Exchange (Fig. 2) have shown thatless than one-fourth of those aged ,18years meet the ADA HbA1c targetof ,7.5% (58 mmol/mol), and the rateis even lower in teens and young adults.In adults, less than one-third achievethe target of,7.0% (53mmol/mol). De-spite the technological advances, thereappears to be no improvement in themore recently enrolled cohorts (8).Elliott Joslin was prophetic. Just

1 year after the discovery of insulin byBanting and Best, he wrote in his classictextbook (9):

Insulin is a remedy primarily for the wiseand not for the foolish, be they patients ordoctors. Everyone knows it requires brainsto live long with diabetes, but to use insulinsuccessfully requires more brains.

Herein, however, lies another of themost invisible aspects of diabetes. The

human brain, unfortunately, does a poorjob of thinking like a pancreas!

Much like type 1 diabetes, type 2diabetes also presents managementchallenges. Data from the NationalCommittee for Quality Assurance (Fig.3) show that nearly 60% of patientswith type 2 diabetes who have commer-cial insurance are not achieving theADA HbA1c target. Even fewer patientswith type 2 diabetes who have Medic-aid are achieving control. There hasbeen little change over the past decadedespite the introduction of several newdrug classes (10).

Adherence is clearly critical to opti-mize control and to decrease morbidity,mortality, and health care expenditures(Fig. 4). Farr et al. (11) compared adher-ence and persistence among more than200,000 adults with type 2 diabetes ini-tiating dipeptidyl peptidase 4 inhibitors,sulfonylureas, and thiazolidinedionesover a period of 3 years. Medication ad-herence ranged from 34 to 47% at thetime of the first-year follow-up, drop-ping to around 28–40% at the second-year follow-up (11,12).

Why don’t health care providershave a sense of urgency to help patientsto close the gap between the currentreality and optimal diabetes manage-ment? Why haven’t the psychosocialand behavioral aspects of the disease,which are so critical to better manage-ment, been addressed?

Bad news and controversy sell best,but there is some good news. We havecome a long way as a result of the hardwork and commitment of many in themedical community at large. Within

the past 25 years, there have been sig-nificant advances in decreasing morbid-ity and mortality in those affected bydiabetes. The hallmark Diabetes Controland Complications Trial (DCCT) and UKProspective Diabetes Study (UKPDS)have shown that tight control reducescomplications and heralded the era ofintensive management.

At the population level, Gregg andcolleagues (13) at the Centers for Dis-ease Control and Prevention showedsubstantial achievements in reducingcomplications between 1990 and 2010(Fig. 5). Rates of myocardial infarction,death from hyperglycemic complica-tions, and end-stage renal disease de-clined by 68, 64, and 28%, respectively.Rates of stroke and amputations bothfell by 52%. All-cause mortality declinedby 23%, and among adults with diabe-tes, cardiovascular disease death ratesdeclined by 40%.

As age-related mortality has declined,the net result is both good news and badnews. Analyses of nationally representa-tive data from 1980 to 2012 (Fig. 6)suggest a doubling of the incidenceand prevalence of diabetes from 1990to 2006 and a plateau between 2008and 2012, but with a continued increasein the incidence among Hispanic andblack populations. Thus, decreasedmor-tality leads to increasing diabetes prev-alence and hence an increase in theoverall number of years lived with dia-betes and in predicted total number ofcomplications (14).

There have been many great publichealth achievements since 1900 suchas vaccination, control of infectious

Figure 2—The minority of patients with type 1 diabetes, both children and adults, are achiev-ing targets. Less than one-fourth of those aged ,18 years meet the ADA HbA1c targetof ,7.5% (58 mmol/mol), and the rate is even lower in teens and young adults. In adults,less than one-third achieve the target of,7.0% (53mmol/mol). Printed with permission fromT1D Exchange (8).

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diseases, safer work places, safer food,healthier mothers and babies, familyplanning,motor vehicle safety, and recog-nition of tobacco use as a health hazard. Itis important to realize the reason that di-abetes, the new public health epidemic, isnot receiving the same attention. Considerthe lessons learned from the followinghealth crises and how they may relate tothe diabetes movementdthe decline indeaths due to coronary artery diseaseand stroke, the fact that some cancersare curable, and the advancementsin HIV prevention and treatment.Let’s examine the impact of biomedi-

cal research on U.S. health. U.S. life ex-pectancy has increased by 10 years overthe past 50 years. Cardiovascular dis-ease death rates have fallen by morethan 70% in the last 60 years. Cancer

death rates are now decreasing by1–2% per year; each 1% drop is savingabout $500 billion. Antiretroviral ther-apy has been themost globally impactfullifesaving development of medical re-search in the 21st century. There hasbeen virtual eradication of mother-to-child HIV transmission, and HIV/AIDStherapies now enable people in their20s to live a full life span (15,16).

Why has the decline in the incidenceof HIV/AIDS been achieved, whereasthe epidemic of diabetes remains un-checked? If we compare disease prev-alence in the U.S., there are nearly 30million people with diabetes, 14 millionwith cancer, and just more than 1 millionwith HIV/AIDS (Fig. 7). The analysis of theNational Institutes of Health (NIH) dollarsspent shows that diabetes funding pales in

comparison with cancer and HIV/AIDSfunding. Apaltry $34.71 is spent comparedwith more than $2,500 per patient withHIV/AIDS (17–19).

What can the diabetes communitylearn from the HIV/AIDS movement?Its origins began with an army of ad-vocates who turned up the heat andtook HIV/AIDS to 212° (Fig. 8). Theycreated a sense of urgency, demandedchange, and achieved phenomenal re-sults in a few decades. At times, theywere confrontational in their demandsand did what they deemed necessaryto get the attention they deserved,but they were smart and very wellprepared to go toe-to-toe with policy-makers, scientists, and corporate exec-utives. They did not “go quietly into thenight”; instead, they were unwilling toaccept stigma and blame, denial, igno-rance, fear, or isolation. They fought withgrassroots advocacy, enhanced self-image,access, voice, and readily measurable out-comes. And they won!

The HIV/AIDS community engaged incollaborative research efforts, datasharing, and out-of-the-box thinkingthat accelerated research and achievedshort-term successes, which, in turn, led tosubstantially more research funding. Thismovement fundamentally changed themedical research paradigm. It changedhow research is conducted, how drugs areapproved, how data are shared, and howpatients engagewith all areas of the federalgovernment as well as the private sector.

Figure 3—Nearly 60% of patients with type 2 diabetes who have commercial insurance are notachieving the ADA HbA1c target. Even fewer patients with type 2 diabetes who have Medicaidare achieving control (10).

Figure 4—Medication adherence in patients with type 2 diabetes (11,12). DPP-4i, dipeptidyl peptidase 4 inhibitors; GLP-1 RA, glucagon-like peptide1 receptor agonists; SU, sulfonylureas; TZD, thiazolidinediones.

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Diabetes, including prediabetes, po-tentially affects one of every three peo-ple in theU.S. How is this not anepidemic?That it is not dealt with with the urgencyof a “crisis”? That it does not have a “war”called upon it by the leaders of the societyin comparison with some other diseasestates?We have seen tremendous advances,

but we are not yet in a position to giveKatie the ultimate answer that she islooking for. Technological innovationshave led to the development of insulinpens and pumps, mealtime insulin ad-ministration, and continuous blood glu-cose monitoring en route soon to thedevelopment of an artificial pancreas.However, insulin is not a biologicalcure. Enhanced understanding ofb-cell biology has led to replacementof b-cell function. This sets the stage

for effective therapeutic progress, butas yet there is no cure. We now knowthat type 1 diabetes is a readily predict-able immune-mediated disease, yet thedisease cannot be prevented. Withoutprevention, there is unlikely to be a cure.

Whether myth or fact, there is a fas-cinating story about a 19th centuryscience experiment. As the story goes,researchers found that when they put afrog in a pan of boiling water, the frogimmediately leapt out. In contrast,when they placed a frog in cool waterthat was slowly heated, the frog justsat there not realizing it was beingboiled to death.

The results of the experiment are agood metaphor for what is required fortransformational change. The frog in coolwater is analogous to complacency,which is the undoing of transformational

change. In contrast, the frog put into boil-ingwater has the urgent sense of impend-ing doom and does something about it.However bold it may be, it acted!

The immediacy of the Zika virus hasrecently grabbed the public’s attention.Immediacy means urgency and crisis,which means proper attention, resourc-ing, and prioritization. Just 3 weeksprior to this lecture, the U.S. Senateapproved a $1.1 billion compromisebill to combat Zika (20).

THE TIME IS NOW FOR US TO TAKEDIABETES TO 212°

Diabetes is the “global warming” ofhealth caredanother calamity in themak-ing that is being conspicuously ignoredwhile HIV/AIDS, the Zika virus, and otherinfectious diseases and epidemics grabthe spotlight.

Those who are and will be affected bythis insidious, invisible disease have aright to demand a fierce urgency ofNOW! We can do for patients with di-abetes what has been done for thosewith HIV/AIDS.

NOW IS THE TIME FOR ADVOCACYAT 212°

We need an army of advocates to fightfor substantially increased funding fromboth the public and the private sectorsthat is sustained and flexible so we canaccelerate research. We must advocatefor better and more affordable treat-ments for patients and better reim-bursements for those who care forthem.

We must also end discrimination inschools and places of work. The ADAcontinues to lead the way, but moremust be done.

NOW IS THE TIME FOREDUCATION AT 212°

We should demand more education andsupport. We should demand reimburse-ments for multidisciplinary teams in-cluding nutritionists, psychologists,certified diabetes educators, and otheressential personnel.

Now is the time for an awareness cam-paign to transition this disease from invisi-ble to visible to both the public and themedical community. Imagine a worldwhere no more children die of diabeticketoacidosis, where we remove thestigma and judgment from those withtype 2 diabetes, and where we actually

Figure 5—Trends in the occurrence of diabetes-related complications from 1990 to 2010 amongadult population with diagnosed diabetes (13). ESRD, end-stage renal disease.

Figure 6—Analyses of nationally representative data from 1980 to 2012 suggest a doubling ofthe incidence and prevalence of diabetes from 1990 to 2006 and a plateau between 2008 and2012 (14).

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help them to get their HbA1c under long-term control!

NOW IS THE TIME FOR MORERESEARCH AT 212°

We need to push that urgency button byasking the bigger, more personally con-frontational questions. Why aren’t wefurther along? Why have we not yetfound a cure? Is there something morewe are not doing? We need to think out-side the box. We need to share data andremove the barriers to collaboration,which has been shown to be the singlebiggest component of innovation. We

need to ask, what have we done todayand what will we do tomorrow to act,speak out, and demand action?

Will we be able to answer Katie’squestions in the next 3–5 years? To trulyconfront this invisible disease, we can-not be trapped by dogma, conventionalwisdom, or the inertia of the status quo.Stand up. Speak up. Do not let the noiseof others’ opinions drown out your owninner voice.

Florence Nightingale, a strong-willed nurse and advocate for her pa-tients and her profession, wisely said,“I think one’s feelings waste themselves

in words; they ought all to be distilledinto actions which bring results” (21).

The work of the diabetes researchand medical communities are more im-portant than ever. For the waters ofdiabetes to reach boiling point at212°, every molecule has to be en-gaged. Every molecule needs that fieryurgency that now is the time. The ADAScientific Sessions offers a platform foruniting the collective voices of thiscommunity and creating a sense of ur-gency to confront and change thecourse of the diabetes epidemic.What we think or what we knowor what we believe in the end is oflittle consequence. The only thingof consequence is what we do andwhat impact it has. Our profession isresponsible for real action capable ofturning the tide of this epidemic andfinding a cure.

Acknowledgments. I thankmy fellow principalofficers Robin Richardson, Maggie Powers, andLorrie Welker Liang who work so hard for theAssociation. The ADA staff led by Kevin L. Haganare truly exceptional. All have a shared passion.I want to thank my clinical and scientific col-leagues who are invariably constructive, inspir-ing, andevenentertaining at times. I havealwaysbelieved that achievement is less about talentthan opportunity. I came to the University ofFlorida in the early 1980s and was fortunate tofind myself in the presence of a rich environ-ment dedicated to improving the lives of allpeople with type 1 diabetes. I have had won-derful mentors in Douglas J. Barrett, ArlanRosenbloom, Janet Silverstein, Noel Maclaren,and Jay S. Skyler. For the past 30 years,my careerhas been closely intertwined with my friendand colleagueMark Atkinson. I am constantly in-spired bymypatients andmy colleaguesMichaelHaller, Clayton E. Mathews, Clive H. Wasserfall,Martha Campbell-Thompson, William Winter,and ToddM. Brusko. I cannot thank Cynthia AyrisKemp, Anastasia Albanese-O’Neill and CassidyO’Neill, and Norma Kerr enough, as well asMatt Petersen, Robert E. Ratner, RichardJ. Farber, Bruce Taylor, Bobbie Alexander, GregBaird, John Griffin, and Kelly Close, among somany others, who have provided inspirationfor the address.The most important recognition must be re-

served for my family. What is never invisible tome is the support of my wife Nadine, both inraising our family and throughout my career.I also thank my children Richard, Megan, andIlyssa who felt the urgency to attend the meet-ing. They, like each and every oneofmypatients,are not only always supportive but are also adriving source of inspiration and wonder.Duality of Interest. No potential conflicts ofinterest relevant to this article were reported.

Figure 7—Comparison of the disease prevalence and NIH funding shows that NIH fundingfor diabetes pales in comparison with funding for HIV/AIDS and cancer (17–19).

Figure 8—A model of transformational change used by the HIV/AIDS movement to create asense of urgency and achieve phenomenal results in a few decades.

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