[Senate Hearing 106-304] [From the U.S. Government Publishing Office] S. Hrg. 106-304 CONQUERING DIABETES: ARE WE TAKING FULL ADVANTAGE OF THE SCIENTIFIC OPPORTUNITIES FOR RESEARCH? ======================================================================= HEARING before the PERMANENT SUBCOMMITTEE ON INVESTIGATIONS of the COMMITTEE ON GOVERNMENTAL AFFAIRS UNITED STATES SENATE ONE HUNDRED SIXTH CONGRESS FIRST SESSION __________ OCTOBER 14, 1999 __________ Printed for the use of the Committee on Governmental AffairsU.S. GOVERNMENT PRINTING OFFICE 61-160 cc WASHINGTON : 2000 ------------------------------------------------------------------------------ For sale by the U.S. Government Printing Office Superintendent of Documents, Congressional Sales Office, Washington, DC 20402 COMMITTEE ON GOVERNMENTAL AFFAIRS FRED THOMPSON, Tennessee, Chairman WILLIAM V. ROTH, Jr., Delaware JOSEPH I. LIEBERMAN, Connecticut TED STEVENS, Alaska CARL LEVIN, Michigan SUSAN M. COLLINS, Maine DANIEL K. AKAKA, Hawaii GEORGE V. VOINOVICH, Ohio RICHARD J. DURBIN, Illinois PETE V. DOMENICI, New Mexico ROBERT G. TORRICELLI, New Jersey THAD COCHRAN, Mississippi MAX CLELAND, Georgia ARLEN SPECTER, Pennsylvania JOHN EDWARDS, North Carolina JUDD GREGG, New Hampshire Hannah S. Sistare, Staff Director and Counsel Joyce A. Rechtschaffen, Minority Staff Director and Counsel Darla D. Cassell, Administrative Clerk ------ PERMANENT SUBCOMMITTEE ON INVESTIGATIONS SUSAN M. COLLINS, Maine, Chairman WILLIAM V. ROTH, Jr., Delaware CARL LEVIN, Michigan TED STEVENS, Alaska DANIEL K. AKAKA, Hawaii GEORGE V. VOINOVICH, Ohio RICHARD J. DURBIN, Illinois PETE V. DOMENICI, New Mexico MAX CLELAND, Georgia THAD COCHRAN, Mississippi JOHN EDWARDS, North Carolina ARLEN SPECTER, Pennsylvania K. Lee Blalack, II, Chief Counsel and Staff Director Linda J. Gustitus, Minority Chief Counsel and Staff Director Mary D. Robertson, Chief Clerk C O N T E N T S ------ Opening statements: Page Senator Collins.............................................. 1 Senator Edwards.............................................. 10 Senator Levin................................................ 14 WITNESSES Thursday, October 14, 1999 Phillip Gorden, M.D., Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health......................................................... 5 Ryan Dinkgrave, Livonia, Michigan, on behalf of the Juvenile Diabetes Foundation............................................ 17 Pam Fernandes, Needham, Massachusetts............................ 18 Gordon Jump, Coto de Caza, California............................ 20 William H. Fuller, Jr., Virginia Beach, Virginia................. 23 C. Ronald Kahn, M.D., Executive Vice President and Director, Joslin Diabetes Center, Boston, Massachusetts, and Former Chairman, Diabetes Research Working Group...................... 26 Edward H. Leiter, Ph.D., Senior Staff Scientist, The Jackson Laboratory, Bar Harbor, Maine.................................. 30 Senator Spencer Abraham, a U.S. Senator from the State of Michigan....................................................... 33 Jeffrey A. Bluestone, Ph.D., Director, Ben May Institute for Cancer Research, University of Chicago, Chicago, Illinois...... 34 Alphabetical List of Witnesses Abraham, Hon. Spencer: Testimony.................................................... 33 Prepared statement........................................... 33 Bluestone, Jeffrey A. Ph.D.: Testimony.................................................... 34 Prepared statement........................................... 89 Dinkgrave, Ryan: Testimony.................................................... 17 Prepared statement........................................... 62 Fernandes, Pam: Testimony.................................................... 18 Prepared statement........................................... 65 Fuller, William H. Jr.: Testimony.................................................... 23 Prepared statement........................................... 73 Gorden, Phillip, M.D.: Testimony.................................................... 5 Prepared statement........................................... 45 Jump, Gordon: Testimony.................................................... 20 Prepared statement........................................... 68 Kahn, C. Ronald, M.D.: Testimony.................................................... 23 Prepared statement with attached charts...................... 75 Leiter, Edward H., Ph.D.: Testimony.................................................... 30 Prepared statement........................................... 86 Exhibits * May Be Found In The Files of the Subcommittee 1. Chart: ``Increasing Deaths Due to Diabetes''................ 93 2. Chart: ``Diabetes: Research Investment vs. Medicare Costs''. 94 3. Chart: ``Diabetes Research as Fraction of NIH Total''....... 95 4. Chart: ``Rising Prevalence of Diabetes in the U.S.''........ 96 5. ``The Family's Guide To Diabetes,'' Web site of Ryan Dinkgrave, Livonia, Michigan................................... 97 6. a. Conquering Diabetes--A Strategic Plan for the 21st Century, A Report of the Congressional-Established Diabetes Research Working Group, 1999................................... * 6. b. Summary of the Report and Recommendations of the Congressionally-Established Diabetes Research Working Group.... 100 7. Charts presented by Dr. C. Ronald Kahn: a. ``Increasing Deaths Due To Diabetes''.................. 115 b. ``The Economic Impact of Diabetes is Staggering''...... 116 c. ``The Economics of Diabetes''.......................... 117 d. ``Goals of the DRWG Plan''............................. 118 e. ``Components of the DRWG Strategic Plan''.............. 119 f. ``Budget Recommendations''............................. 120 8. Statement for the Record of the American Diabetes Association.................................................... 121 9. Statement for the Record of the American Association of Diabetes Educators............................................. 130 10. Statement for the Record of Arnauld E. Nicogossian, M.D., Associate Administrator, Office of Life and Microgravity Sciences and Applications, National Aeronautics and Space Administration................................................. 134 11. Diabetes Overview, National Diabetes Information Clearinghouse (NIDDK).......................................... 137 12. The Vision of Pam Fernandes, Diabetes Forecast, September 1999........................................................... 153 CONQUERING DIABETES: ARE WE TAKING FULL ADVANTAGE OF THE SCIENTIFIC OPPORTUNITIES FOR RESEARCH? ---------- THURSDAY, OCTOBER 14, 1999 U.S. Senate, Permanent Subcommittee on Investigations, of the Committee on Governmental Affairs, Washington, DC. The Subcommittee met, pursuant to notice, at 9:30 a.m., in room SD-628, Dirksen Senate Office Building, Hon. Susan M. Collins, Chairman of the Subcommittee, presiding. Present: Senators Collins, Levin, and Edwards. Also attending: Senator Abraham. Staff present: K. Lee Blalack, Chief Counsel and Staff Director; Mary D. Robertson, Chief Clerk; Kirk E. Walder, Investigator; Elizabeth Hays, Staff Assistant; Ryan Blalack, Intern; Leslie Bell, Minority Congressional Fellow; Priscilla Hanley and Felicia Knight (Senator Susan M. Collins); Butch Burke (Senator Ted Stevens); Anne Bradford (Senator Fred Thompson); Laurie Armstrong (Senator John Edwards); Allison Dehosky and Erin Quay (Senator Arlen Specter); and Natacha Blain (Senator Richard Durbin). OPENING STATEMENT OF SENATOR COLLINS Senator Collins. The Subcommittee will please come to order. Good morning. Today the Permanent Subcommittee on Investigations is holding an oversight hearing to examine the impact that diabetes has on Americans, and to determine whether Federal funding for diabetes research is sufficient to take advantage of the unprecedented opportunities for progress toward better treatments, prevention and ultimately a cure. Diabetes is a devastating condition that affects people of every age, race and nationality. Sixteen million Americans suffer from diabetes, and about 800,000 new cases are diagnosed each year. Moreover, diabetes frequently goes undiagnosed. Of the 16 million Americans with diabetes, an estimated 5.4 million do not realize that they have the disease, with the result that its serious consequences go untreated. Diabetes is one of our Nation's most costly diseases, both in human and economic terms. It is the fifth deadliest disease in the United States, and kills almost 200,000 Americans annually. As this chart illustrates,\1\ while the death rate for other common life-threatening diseases, like cardiovascular disease and stroke, has declined in recent years, the death rate due to diabetes has actually increased by 30 percent since 1980. --------------------------------------------------------------------------- \1\ See Exhibit No. 1, which appears in the Appendix on page 93. --------------------------------------------------------------------------- Diabetes is also the leading cause of kidney failure; blindness in adults; and amputations not related to injury. It is a major risk factor for heart disease, stroke, birth defects, and shortens life expectancy by up to 15 years. In addition to the human toll of diabetes, this disease costs the Nation in excess of $105 billion annually in health- related expenditures. At present, more than one out of every ten health care dollars and about one out of every four Medicare dollars are spent each year treating people with diabetes. Indeed, taxpayers spend more than $40 billion a year treating people with diabetes through various programs such as Medicare, Medicaid, Veterans and Federal employees health programs. In stark contrast, only about 3 percent of the budget of the National Institutes of Health is devoted to research on diabetes and its complications. This second chart illustrates the huge disparity between the cost of treating just Medicare patients and the amount of the Federal investment in diabetes research.\1\ If we looked at all Federal programs, the disparity would be even greater. --------------------------------------------------------------------------- \1\ See Exhibit No. 2, which appears in the Appendix on page 94. --------------------------------------------------------------------------- What is particularly alarming to me is that the inadequate investment in research has occurred at a time when the percentage of Americans with known diabetes has increased dramatically. The number of diagnosed cases of diabetes has almost doubled since 1970. This trend is only expected to accelerate in the 21st Century as our population ages. Unless dramatic changes occur and occur soon, the number of Americans with diabetes will climb to 23 million over the next 10 years. There currently is no way to prevent or cure diabetes, and available treatments have had only limited success in controlling its devastating consequences. The problem is made all the more complex because diabetes is not a single disease. Rather, it occurs in several forms and has complications that affect virtually every system of the body. Children with type 1 diabetes face a lifetime of daily finger pricks to check their blood sugar levels, daily insulin shots, and the possibility of complications such as kidney failure and blindness which can be disabling and even deadly. Older Americans with type 2 diabetes can also be disabled by the multiple complications of this serious disease. Recently I had the opportunity to meet a courageous 8-year- old boy from North Yarmouth, Maine. His name is Nathan Reynolds, and he epitomizes for me why it is so important to accelerate our fight against diabetes. Nathan is an active young child. He enjoys school, biking, swimming, baseball, and collecting old coins. He was diagnosed with diabetes in December 1997, a diagnosis that has forever changed his life and the life of his family. He has had to learn how to draw his blood, something his 4- year-old brother reminds him to do before every meal. He has to check his blood sugar level and give himself an insulin shot. What to me is saddest of all, is that Nathan can never take a day off from his diabetes. It does not matter if it is his birthday, it does not matter if it is Christmas, he still has to take those shots every single day. The fact that diabetes, once diagnosed, is a lifelong condition, was underscored by a 65-year-old man who recently wrote to me that he estimated he had given himself 76,000 insulin shots since he was first diagnosed with diabetes at age 15; 76,000 shots. The good news for children like Nathan and our witnesses today is that promising research is underway that may lead to medical breakthroughs for those with both type 1 and type 2 diabetes. The next decade holds tremendous promise for diabetes research. Improvements in technology and the general growth in scientific knowledge have created unprecedented opportunities for medical advances that should lead to better treatments, prevention, and ultimately a cure for children like Nathan. Earlier this year, the congressionally sponsored Diabetes Research Working Group issued its report entitled ``Conquering Diabetes: A Strategic Plan for the 21st Century.'' \1\ The report details the magnitude of the problem and provides a comprehensive plan for NIH-funded diabetes research. --------------------------------------------------------------------------- \1\ Exhibit No. 6.a. is retained in the files of the Subcommittee. --------------------------------------------------------------------------- In the report, the Working Group finds that many scientific opportunities are not being pursued due to insufficient funding, lack of appropriate mechanisms, and a shortage of trained researchers. The report also concludes that the current funding, level of effort, and scope of diabetes research falls far short of what is needed to capitalize on these opportunities; and, further, that the funding level is far short of what is required to make progress on this complex and difficult problem. The report recommends funding of $827 million for diabetes research at NIH in fiscal year 2000. Last week, I am pleased to report, the Senate approved a Labor-HHS appropriations bill increasing funding for NIH by $2 billion, a very positive development. Senator Breaux, who serves as co-chair with me of the Diabetes Caucus in the Senate, helped me win passage of an amendment to that bill calling for increased support for diabetes research in accordance with the recommendations of the Diabetes Research Working Group. The unanimous Senate vote for this amendment sends a strong and clear signal that diabetes research is a high priority for the U.S. Senate. Diabetes has been underfunded in the past, and it is imperative that we ensure that sufficient resources are available to take full advantage of the extraordinary opportunities we have to better understand and ultimately conquer this devastating disease. This morning's hearing is intended to examine the effects that diabetes and its resulting complications have had on Americans of all ages in both human and economic terms. We will also hear from researchers who will talk about the scientific opportunities available in diabetes research and the work that they are doing to find better treatments, a means of prevention, and ultimately a cure. I would note that I am particularly proud that The Jackson Laboratory in Bar Harbor, Maine, have been leaders in this research. Finally, we will discuss future funding levels for diabetes research, and how we can be helpful in ensuring that NIH does complete the commitment that the Senate has underscored must be kept. I very much look forward to the testimony of our witnesses today, and to learning more about this critically important issue of public health. Due to the time constraints of this hearing, the Subcommittee was unable to invite everyone affected by this issue to present oral testimony. We have already received two written statements, one from the American Diabetes Association and the other from NASA, making the Subcommittee aware of NASA's ongoing contributions to biomedical research and in particular diabetes research. I must say that I personally was unaware of NASA's contributions in this area, and I appreciated their providing us with this testimony. Without objection, these statements and any others that the Subcommittee receives in the next 10 days will be included in our printed hearing record.\1\ --------------------------------------------------------------------------- \1\ See Exhibits No. 8-10, which appears in the Appendix on page 121-134. --------------------------------------------------------------------------- Before proceeding to our first witness, I want to take the opportunity to say that the order of witnesses for this morning's hearing is not what I had originally planned. We had originally planned to have the administration's representative testify on the last panel, so that he would have the opportunity to hear and to respond to the concerns raised by diabetes patients, their families, and by some of the leading scientists in the field of diabetes research. The Department of Health and Human Services liaison, however, informed the Subcommittee that they would ``not allow'' Dr. Gorden to testify unless he testified first and on a panel of his own. I want to make very clear that I realize this was not Dr. Gorden's decision and I certainly do not hold him personally accountable for the ill-advised policy by the Department of Health and Human Services, but I want to say for the record that I think HHS's policy in this regard is both unfortunate and very arrogant. It seems to me that it suggests that the Clinton Administration does not want to be held accountable for its decisions. And, moreover, I would think that NIH would be concerned and HHS would be concerned that this policy only serves to reinforce criticisms voiced by the Institute of Medicine and others, that NIH is not sufficiently involving patients and their families, the ones who have the most at stake, in the process of setting research priorities. I understand that research allocation decisions should be made on the basis of sound science, but also it clearly should take into account the human toll of the disease. I do want to again say I realize this is not Dr. Gorden's fault and it is not his policy, but I did want to express for the record my strong disagreement with HHS's decision and its policy in this matter. I also understand that Dr. Gorden is going to try to remain for the duration of the hearing so that he can do what our intention was, and that is hear the testimony of the other witnesses, and I want to express my personal appreciation for his willingness to do so. Having said that, our first witness this morning is Dr. Phillip Gorden. He serves as the Director of the National Institute of Diabetes and Digestive and Kidney Diseases, which is part of the National Institutes of Health. Dr. Gorden began his career at NIH in 1966 as a senior investigator in the Clinical Endocrinology Branch of the NIDDK. Dr. Gorden became the Director of the National Institute of Diabetes and Digestive and Kidney Diseases in 1986. We very much look forward to hearing his testimony. Dr. Gorden, under our Subcommittee rules, we have to swear in each and every witness, so I am going to ask that you stand, pursuant to Rule 6. [Witness sworn.] Senator Collins. Thank you very much. You may proceed. TESTIMONY OF PHILLIP GORDEN, M.D.,\1\ DIRECTOR, NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES, NATIONAL INSTITUTES OF HEALTH Dr. Gorden. Senator Collins, I would like to first assure you that I will be available to you throughout the entire course of your hearing. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Gorden appears in the Appendix on page 45. --------------------------------------------------------------------------- With your permission I would like to add just one brief personal note to express, on behalf of the Department and the NIH, our sincere appreciation to Dr. Kahn for his work in chairing the Diabetes Research Working Group, and to all the members of that committee who worked so hard to put their report together. In addition, I would appreciate if you would let the record of this Subcommittee show that we extend our congratulations to him on the marriage of his daughter, Stacy Anne, which took place only 4 days ago. Thank you very much for that. Senator Collins. He does indeed have a lot to be proud of. Thank you. Dr. Gorden. Madam Chairman, I am very pleased to have the opportunity to testify this morning as the Director of the National Institute of Diabetes and Digestive and Kidney Disease, which has lead responsibility for diabetes research at the National Institutes of Health and within the Department of Health and Human Services. I very much appreciate the opportunity to tell you about the Department's efforts to combat diabetes, with emphasis on our biomedical research program. As you have mentioned, in both human and economic terms, diabetes is an extremely costly disease. It is widely recognized as one of the leading causes of death and disability in the United States and throughout the world. Diabetes affects an estimated 16 million Americans, about half of whom do not know they have the disease and are not being appropriately treated for it. Approximately 800,000 people are diagnosed with diabetes each year, including both genders, the young, the old, all races and ethnic groups, the rich and the poor. Although diabetes occurs most often in older individuals, it is one of the most common chronic disorders in children in the United States. About 120,000 children and teenagers younger than age 19 have diabetes. Both type 1 and type 2 diabetes are associated with the eye, kidney and peripheral nerve complications, as well as heart attack and stroke. According to the American Diabetes Association, diabetes and its complications cost an estimated $98 billion annually. Though there are several interventions currently available to help reduce the burden of this disease, there are no methods to cure it or to prevent its onset. The Department has a multifaceted agenda to combat diabetes. Diabetes is an important trans-NIH research area because the disease and its complications affect multiple organ systems. The scientific direction of the broad NIH diabetes research program has been recently augmented by recommendations we have received from a special trans-NIH symposium on diabetes scientific opportunities and challenges, as well as by the identification of scientific opportunities and needs in the strategic plan developed by the congressionally established Diabetes Research Working Group. NIH diabetes research is complemented by programs of the Centers for Disease Control and Prevention, the Indian Health Service, and other parts of the Department. We have also established productive collaborations with the American Diabetes Association and the Juvenile Diabetes Foundation International, as well as the biotechnology and pharmaceutical industries. Remarkable advances in both fundamental and clinical science are having an enormous positive effect on diabetes research and treatment. These include rapid advances in genetics and genomics, new discoveries of mechanisms to manipulate the immune system, a major new understanding of cell communication, and key advances in clinical science, such as blood pressure and lipid control, which are crucial to the treatment of diabetes. Two major clinical trials have demonstrated that the complications of diabetes can be ameliorated or prevented through close control of blood glucose levels. These important clinical results, coupled with the demonstrated efficacy of laser photocoagulation in treating diabetic eye disease, and the use of drugs such as ACE inhibitors in ameliorating the kidney disease of diabetes, all represent major steps forward in our continued quest for more effective treatment, and ultimately, prevention and cure of the disease. In type 1 diabetes, we are pursuing multiple research avenues in the search for underlying causes of this disease, together with new treatment and prevention strategies. We are searching for clues to what causes the body to attack and destroy its insulin-producing cells, the hallmark of type 1 diabetes. We are also embarking on a new and exciting initiative to restore insulin-producing capacity through islet cell transplantation. This research is propelled by a remarkable study in primates, showing that both insulin-producing islet cells and kidneys can be transplanted using a highly selective method to control for immune rejection of the transplant. We have also a major clinical trial aimed at preventing or delaying the onset of type 1 diabetes in individuals at risk, and we are seeking to develop more effective ways to achieve good glucose control. In type 2 diabetes, we are gaining new insights into the mechanism of insulin action, which provides new therapeutic options to combat the body's resistance to insulin, a characteristic abnormality of this disease. We also have a major research initiative on obesity, a serious risk factor for type 2 diabetes. In fundamental research, the discovery of the obesity gene and its protein product, leptin, in mice have provided new insight into mechanisms of obesity and both the control of eating disorders and energy regulation. The fundamental observations underlying this discovery were made at The Jackson Laboratory years ago. These findings have now spearheaded the discovery of at least five different genetic defects in humans that lead to obesity, and may provide new insight into the interrelationship between obesity and type 2 diabetes. We have also launched a major clinical trial in which drug and lifestyle interventions are being studied to see whether they can delay or prevent the onset of type 2 diabetes. Over 50 percent of the patients in the trial are from minority populations who suffer disproportionately from the high burden of this disease. A second multicenter clinical trial is designed to study the health benefits of long-term weight loss in type 2 diabetic patients. Furthermore, the National Heart, Lung and Blood Institute has inaugurated a major clinical trial to determine whether glucose control can augment the beneficial effects of blood pressure and cholesterol control in ameliorating the vascular disease of diabetes that leads to heart attack and stroke. Madam Chairman, I am grateful for the opportunity to share with you some examples of our efforts and progress in combating diabetes. I have tried to underscore today that we understand the great burden that diabetes places on families, patients and communities. A number of those individuals are here with us today to demonstrate that even further. At the same time, I want to share my feeling of encouragement and hope. I believe that our strong national programs hold the essential key to curing this disease. We have important programs under way, but much more remains to be done. I am very pleased to answer any questions that you may have. Senator Collins. Thank you very much, Dr. Gorden. I am going to direct your attention to Exhibit 3.\1\ And if I could have Exhibit 3 put up, also, I believe it is in the notebook before you if it is not clear from the chart. --------------------------------------------------------------------------- \1\ See Exhibit No. 3, which appears in the Appendix on page 95. --------------------------------------------------------------------------- Dr. Gorden, as I mentioned in my opening statement, I am concerned that only about 3 percent of NIH's budget has been devoted to research on diabetes and its complications. Moreover, if you look at this chart, you can see that the percentage has actually declined over the past 20 years, at the same time that the death rate from diabetes has actually increased by 30 percent. Now, I understand that there is no universally agreed-upon method for determining the appropriate level of research funding, but it seems to me that this is an awfully small investment when you consider that this is a disease that affects about 6 to 7 percent of the population, accounts for 10 percent of all health care expenditures and about 25 percent of our Medicare budget. Your institute is the lead institute for diabetes research. What percentage of your budget is dedicated to diabetes research? I realize there is diabetes research going on in other institutes, as well, but you are the primary one. Dr. Gorden. In NIDDK, we fund approximately 60 to 65 percent of what is coded as diabetes research across the National Institutes of Health. Those funds constitutes about 27 percent of the total budget for NIDDK. Senator Collins. Overall in NIH it is about 3 percent of the research dollars; is that correct? Dr. Gorden. If you were to express the entire NIH budget, which is a very large figure, as a denominator against almost anything else as a numerator, you will come out with a relatively small figure in terms of a specific disease. What I would like to emphasize, and what I think is by far and away the most important, is the part that starts in fiscal year 1997, when we began to see the increased appropriations for NIH, for which we are enormously grateful to the Congress. I believe that what you are seeing now is the benefit of that being translated into research on diabetes. From 1997 there is an upward trend and I think that is what we are really focused on this morning. Senator Collins. Did you request an increase in your budget as part of the budget process going through OMB that the administration presented to Congress? Dr. Gorden. We basically request what the OMB permits us to request, which turns out to be the administration's budget. That request was at a level of approximately a 2.1 percent increase over fiscal year 1998. And this was the budget that NIH presented, as well as the one my individual institute, as well as all the other institutes, presented in our testimony to the Congress this past spring. Senator Collins. So essentially the administration tells you what you are to request for a budget, as opposed to your putting forth what you believe would be the ideal budget to meet the needs and to take advantage of the scientific opportunities? Dr. Gorden. It is a rather complex process. At some point in time we may be asked to present a professional judgment budget, as we were by Senator Specter last year. The formal process then goes through a number of iterations, and in the end we present the administration's consolidated budget. Senator Collins. Did you agree with the administration's proposal to request a budget that would provide an increase for NIH of only 2.5 percent? Dr. Gorden. I think that it is important that we adhere to some common format in terms of our budgetary presentation. In the context of adhering to that format, I agree with the process. I would obviously prefer, on a personal level, to see our level go higher. Senator Collins. Let me ask you what may be an easier question for you to answer, and one that puts you less on the spot. Do you agree with the findings of the Diabetes Research Working Group that diabetes research has been underfunded, and thus we have not been able to take advantage of scientific opportunities? Maybe it is not an easier question, I do not know. Dr. Gorden. I think we need to put in context the fact that the Working Group points out the enormous opportunities in diabetes research that are open to us. They were dealing with a specific disease and making recommendations on a specific disease. Both at NIDDK and across NIH, we must take those recommendations and put them in the context of everything that we do, which is also reflective of language that we receive from the Senate and from the House which underscores the multiplicity of diseases that our research combats. We have to place the recommendation of the Diabetes Research Working Group in context across NIH based on all of the considerations and recommendations that are coming to us. I think that in each disease area we may have concerns about underfunding, and it is difficult to know exactly how one places one of these relative to another. This is really the issue that we face in terms of implementation strategies. I think in terms of recommendations, that this is the way it should be. Senator Collins. The Senate has increased funding for NIH by 13 percent, a far stronger investment than that proposed by the administration. If the 13 percent figure goes through, what funding level would you envision would be provided for diabetes research? Would we be able to approach the $827 million recommended by the Working Group? Dr. Gorden. In the example that you gave, the NIH would receive a 13 percent increase for all the diseases within its mission, but the Working Group calls for over an 80 percent increase for diabetes research alone. We have to deal in some way with the difference between a 13 percent increase and an 80 percent increase. Another issue that I think is a little complicated, when one strictly talks in budget terms rather than scientific terms, is that we were involved with the Working Group's recommendations from its very outset. Because the Congress provided us with a very generous budget in fiscal year 1999, we were able to jump-start some initiatives and lay some of the footprints for many of the Working Group's recommendations across the highest priority areas. When we talk about science, we can talk in logical terms about what is started and what needs to be completed. When we try to translate that into total dollar terms, it becomes a little bit more complicated in terms of how we express it. Senator Collins. I guess my concern, Dr. Gorden, is the Senate has gone on record very strongly in favor of the Working Group's recommendations. The report language in the appropriations bill is equally strong. We provided a 13 percent increase, which I hope will survive in conference. The Senate's goal is to double NIH spending over the next 5 years. There are many of us who have cosponsored a resolution in support of that. I want to know how we are going to get there. I want to know what NIH thinks, whether you are committed to implementing the recommendations of the Working Group, whether NIH shares the commitment of the Senate to providing the necessary research dollars to conquer this devastating disease. I am pleased that we are on the up-tick, but when you look at the impact of this disease versus the resources that we are now putting in it, it is just a huge disparity. And when I visit with scientists, I am so excited about the research that is underway. When I talk to children and adults who have this disease and I see the impact on their lives, I want a breakthrough, and I am convinced we have got to be willing to invest to get there. So I guess what I want to hear from you is, what is the extent of NIH's commitment? Do you agree with the Working Group? Do you have a plan for following the Working Group's recommendations? Are you going to put in the resources that Congress clearly wants you to put in, that this eminent group of scientists and patients have come up with an excellent plan for achieving? What are your intentions? What is your plan? Dr. Gorden. Senator, I want to emphasize what has happened with this up-tick, and I am absolutely confident that it is going to continue. We very much support the recommendations. They are scientifically very sound and solid. We are actively involved in implementation strategies, and implementation strategies are mechanisms to actually place these recommendations into operation. We receive a broad recommendation. We have to translate that into an implementation strategy. We are in the process of making those translations now, as we anticipate over the next possibly 2 weeks to receive an appropriation. At that time I think we will be prepared to move forward in implementing many of the recommendations from the Diabetes Research Working Group. Plans are afoot, certainly within NIDDK. NIDDK is involved in working with the other institutes to canvass their plans and also to stimulate the efforts that have been proposed by the Working Group so that they can be translated across NIH. There is no question that the momentum is there, and we are very excited about moving forward. We share this feeling of excitement about the research opportunities that exist. Senator Collins. From my perspective, it has been Congress that keeps pushing NIH in this direction. It was Congress that established the Diabetes Research Working Group. It was Congress that has given the increases to NIH, despite the administration requesting increases this year that wouldn't even have kept pace with inflation. And I want to yield to my colleague for some questions before I wrap up a couple more areas I want to talk to you about, but I want to send a very strong message that we need you as partners in this fight and we admire NIH. I respect the incredible caliber of scientists and research that you are doing. But we need to make a commitment to getting this job done, and it can't be just the Congress pushing, pushing, pushing. We need a commitment from NIH that puts diabetes research as a priority. Senator Edwards, welcome. OPENING STATEMENT OF SENATOR EDWARDS Senator Edwards. Thank you, Madam Chairwoman. Good morning, Dr. Gorden. Dr. Gorden. Good morning, sir. Senator Edwards. And I apologize, I missed the beginning of your testimony and I listened to just your answers to the most recent series of questions, and I may be being repetitive but I am not sure I understood your answer. Are you saying that NIH is committed to following the Working Group's recommendations? Dr. Gorden. I am saying that the scientific opportunities that are being proposed by the Working Group are opportunities that the NIH is pursuing to implement. Senator Edwards. So the answer is, you are committed to following the recommendations; is that what you are saying? Dr. Gorden. We are committed to following the scientific recommendations of the Working Group. Senator Edwards. One of the issues that has been raised by some of my folks back in North Carolina, for example, Dr. John Busey, who you may know is a diabetes researcher there, has to do with the number of proposals that are made for conducting research in the area of diabetes and the percentage of those proposals that are accepted by NIH. First of all, in the area of diabetes, do you have any idea about what percentage of the proposals that are made to do research in that area are in fact accepted by NIH? Dr. Gorden. In general, we talk about the number of awards for grants, which is the largest expenditure that NIH makes across the board. With the very generous support that we have received from the Congress in the last 2 fiscal years, we now have an award rate of about 33 percent across NIH. That is the proportion of eligible grant applications that are actually awarded. The same is generally true for diabetes. In other words, our award rate for diabetes-related grants would be in the same range as they would be in our institute for digestive disease or kidney-related grants or nutrition-related grants, and that is generally the same across NIH. We fund about one-third of the grant applications we receive, and that is driven by the peer review system. That system evaluates the scientific quality of each individual grant, which is really the bedrock of NIH support of fundamental science. Senator Edwards. Well, my concern is the anecdotal stories I hear, and I hear what you are saying about the percentages, indicate that some of the young researchers become very discouraged in this area because they do a lot of work, they make these proposals, their proposals are rejected. And I guess ultimately what you and I both need to be concerned about is making sure that we are able to attract and retain good researchers, particularly, since we are here talking about diabetes today, in the area of diabetes. Do you have any ideas or thoughts about how to deal with that? Dr. Gorden. Yes. I have been watching this for some time now, and I believe there is nothing more positive to the community and to young investigators or people who are contemplating biomedical science as a career, as what has been provided to NIH over the last 2 fiscal years. These investigators are encouraged by the commitment on the part of the Congress to double the NIH budget. Those are very powerful statements to young investigators who are looking for the interest and the importance of a biomedical research career. They now are seeing that this may be really a viable and secure future for them to pursue, in the sense that resources are going to be available. In my view, nothing has been a more powerful statement for young investigators. In addition to that, we have got to ensure that the young investigators, in diabetes research in particular, have the human infrastructure in place to actually reach the full implementation of all of these recommendations that have been made. That will require furthering the human infrastructure, a goal that we have set. We have set out to establish new kinds of research career mechanisms; to enhance clinical investigation, which is an area that is particularly put upon in the last few years. But, the increased resources that are actually flowing into biomedical research in general have had an enormously positive effect on young people. Senator Edwards. Well, I think I just will point out, and I think you recognize it is critically important that we attract and retain talented people to do research in these areas. Dr. Gorden. I agree completely, Senator. Senator Edwards. In terms of the importance of diabetes research, do you agree with the basic premise that although stroke and heart disease at least superficially appear to cause more deaths, more premature deaths than diabetes, that diabetes is often an underlying cause of both stroke and heart disease? Dr. Gorden. Yes, that is true. Senator Edwards. And so sometimes the importance of diabetes, at least if you only look at the superficial information, is underestimated. Dr. Gorden. That is absolutely true. Senator Edwards. So whatever we can do in the way of diabetes research and prevention of diabetes also has a direct impact on premature deaths caused by stroke and heart disease? Dr. Gorden. Absolutely. I would like to add that, for instance, we met recently with the American Heart Association, which has decided to make diabetes one of its major risk factors. If you recall, hypertension, cholesterol and smoking have been key risk factors for their public relations campaign. Now diabetes is added to that. Although diabetics have benefited tremendously from the same interventions that have decreased mortality in heart disease and stroke, quantitatively they have not benefited as much, and we have got to find the reason for that. What is that additional increment of risk that diabetics have, that is related to diabetes per se in some way? We are not certain what that risk is. Now, if you are a diabetic and you smoke, this is really bad. If you are anybody and you smoke, it is really bad. But if you are a diabetic and you are hypertensive, that is a very bad situation. These things all are additive and are synergistic, really, as risk factors. In our prevention studies, we are trying very hard to reduce this other layer of risk, and trying to find what it is about diabetes that creates this additional risk for cardiovascular disease, which as you point out are heart attack and stroke. This is a very important objective in this whole enterprise. Senator Edwards. Thank you, Dr. Gorden. We appreciate very much the work you do at NIH. I think it is critically important. I would just emphasize what Senator Collins said just a few moments ago, which is, we believe it is so important that the diabetes research that needs to be done is focused on, that the Working Group's recommendations are in fact implemented. In my State of North Carolina diabetes is an enormous problem, and for a variety of reasons. So we would just like to see you continue the up-tick that you show on your chart, and would like very much to see the recommendations of the Working Group followed. Dr. Gorden. Thank you, sir. Senator Edwards. Thank you, Dr. Gorden. Senator Collins. Thank you, Senator. Dr. Gorden, I just have a couple more questions for you. Since diabetes has complications that affect virtually every system in the body, it is not surprising that other institutes at NIH are also involved in diabetes research. One concern that I have heard from scientists and from advocates for the diabetes community is that there is insufficient collaboration among the institutes in planning diabetes research. What are your plans to improve collaborative efforts so that you do have the most bang for the buck, you do have a synergistic effect of your research? Dr. Gorden. I think this is a very important issue. I think that this new emphasis on both collaboration with other institutes and trans-NIH support is fueled by several things. We created one model in the special appropriation of the Balanced Budget Act of 1997, which was a special appropriation for type 1 diabetes. Though NIDDK is the principal administrator of that initiative at NIH, it is clearly a trans- NIH effort. We have achieved that by working through the Diabetes Mellitus Coordinating Committee. We have also done it by working directly with the institute directors in planning the initiatives to go forward. We have taken that model now and have used the increased appropriations that you see in fiscal year 1998 and 1999 to propel the momentum in other institutes. When we take the Working Group's plan and their recommendations, we now can look at a spreadsheet and see which recommendations apply most directly to which institutes. We now can communicate directly with those institutes and work with them. For instance, within the last several weeks we had a workshop with the National Institute of Neurological Diseases and Stroke. Neuropathy of diabetes has been recognized as an area that has been underfunded and under-researched. Therefore, we are prepared to join with them to create a major initiative in fiscal year 2000 to address this problem. Similar initiatives are under way with the National Heart, Lung and Blood Institute on macrovascular heart attack and stroke. We have a program that we have inaugurated with them. They have joined with us in our major effort to combat obesity in a clinical trial. These are just a few of the examples of things that are moving forward, and at a much greater rate and momentum than in the past. I feel very comfortable and confident about the collaborative trans-NIH effort for all of these important initiatives, because the essence is that each institute has both resources and expertise, and we need both of those. We need the resources and the expertise that they bring to the table. That is what we are trying to maximally take advantage of in our program development. Senator Collins. The final issue I want to discuss with you concerns reports, very disturbing reports that we are starting to see more type 2 diabetes in teenagers. In fact, just last week when I was in Maine, a dietician came up to me and told me that she is seeing an increase in her practice of diabetic teenagers who are type 2 rather than type 1. What is NIH doing to combat that disturbing trend, and do you have any research underway, perhaps related to life style issues, that you could share with us? Dr. Gorden. This is a very important issue, and we plan to move forward with an initiative in fiscal year 2000 to address this. We want to both define the magnitude of this problem and to define the issues involved in this. We believe that they are similar issues to those occurring in adults with diabetes, but we think that there may be other issues as well. There are issues of obesity in children, which has been an increasing issue in the last 10 years. The increases in obesity and diabetes are interrelated. These cases of obesity are occurring primarily in minority populations, particularly Native Americans and Hispanic populations. There are obviously reasons. Our basic research in genetics and other areas will continue in an attempt to define this in a more fundamental way, but we must address this as a public health emergency quickly, and try to do those things that are going to help ameliorate the problem. That is what we plan to do, initially working through the more basic scientific avenues in terms of the broad area of fundamental science, which is going to ultimately address this problem. We have got to do something about it quickly as a public health issue. It is a major problem. We are very concerned about it. Senator Collins. That development to me shows how complex this issue is. We not only need to be doing research focused on a cure which I feel so strongly about, we also need education efforts to help people manage their diabetes better. We need to work on treatment, prevention, and the cure, and I hope that your research will pay attention to all three of those goals. I want to thank you very much for being with us today, and again I appreciate your willingness to stay and hear from our witnesses. I think we will all learn a great deal from them. Thank you, Dr. Gorden. Dr. Gorden. Thank you very much, Senator Collins. Senator Collins. I am now going to call on Senator Levin, who is our Ranking Minority Member of the Subcommittee, who has a great deal of commitment to this issue. We also have one of his constituents with us today to help us better understand this devastating disease. And I would like to, before we call on our next panel of witnesses, call on Senator Levin for his opening statement and any comments he might want to make in introducing his constituent. OPENING STATEMENT OF SENATOR LEVIN Senator Levin. Madam Chairman, let me thank you first of all for holding this hearing. It is a very important hearing in the battle against diabetes. You have taken a leadership role here which is critically important to the health of the Nation, and I commend you for doing it. It is a really important cause that you have taken the leadership of here. Thank you, for all of us, for doing so. As we all know, diabetes is a pernicious disease that affects people of all ages, and in addition to the ill effects that it creates on its own, it causes a variety of other debilitating medical problems such as heart attack, stroke, kidney failure, blindness, and circulatory failure which can lead to amputation. And all of these complications makes diabetes the sixth deadliest disease in the United States. It annually affects 16 million people, about a third of whom are undiagnosed. It kills about 200,000 people a year. Diabetes afflicts 120 million people worldwide, and the World Health Organization estimates that this number will skyrocket to 300 million within the next 25 years. A new case of diabetes is diagnosed every 40 seconds. It is the leading cause of kidney failure, adult blindness, and nontraumatic amputations. People with diabetes are two to four times more likely to have a heart attack or stroke. Life expectancy of people with diabetes averages 15 years less than that of people without diabetes. Those are the facts that we have to contend with and try to change. In my home State of Michigan, almost 400,000 people have been diagnosed with diabetes. Medical experts believe another 204,000 have the disease but don't yet know it. We have the fifth highest rate of incidence of diabetes in the country, in my State of Michigan. The financial cost can be overwhelming. Until recently, Medicare would not pay for one of the basic management tools, an insulin pump, and I want to commend our Chairman for her efforts in getting that policy changed. We have many witnesses today. One of them is a constituent of mine that we are very proud of, Ryan Dinkgrave from Livonia, Michigan, Stevenson High School, 16 years old. At his young age he has already made a major contribution in the fight against diabetes. He has raised public awareness of this disease, and now wears an insulin pump. He has told us, first, that the emergency medical personnel in his home city were not trained or authorized in the use of advanced life support methods relative to diabetes. Today, advanced life support is part of the training of their emergency medical personnel, and this life support includes the use of an injectable hormone which stimulates the liver to release glucose. Ryan has been very active in educating the people about diabetes in other ways. He has created a Web site called ``The Family's Guide to Diabetes.'' He has been interviewed on national television. He has helped raise funds for diabetes research, and we are very proud of the effort and accomplishments of this young man. We are very delighted that he is here with us today, with his dad, I understand. I want to welcome you, Ryan. I wish I could stay for your testimony. I have read your statement, however, and it is a very eloquent and moving statement. I have to return to another hearing, and the Chairman understands the kind of complications that we have in our senatorial lives. And I thank her again for her leadership, for allowing me to make my opening statement at this time, and to introduce Ryan to the Subcommittee. And finally, Madam Chairwoman, I would ask unanimous consent that a hard copy of Ryan's Web site be inserted in the record. It is a very clever Web site. It will be particularly attractive to young people. Web sites do that generally, but specifically this Web site is designed in a very creative way which will be specifically attractive to young people. So I would ask, Madam Chairman, that we make a hard copy of this Web site as part of our record.\1\ --------------------------------------------------------------------------- \1\ See Exhibit No. 5, which appears in the Appendix on page 97. --------------------------------------------------------------------------- Senator Collins. Without objection. Senator Levin. And, again, my thanks to you for your leadership. Senator Collins. Thank you, Senator Levin. I am delighted to join Senator Levin in welcoming our next panel of witnesses this morning. He has already introduced Ryan, so I will proceed to introduce the other witnesses. Pam Fernandes is from Needham, Massachusetts; Gordon Jump from Coto de Caza, California; and William Fuller, Jr., of Virginia Beach, Virginia. Ms. Fernandes was diagnosed with type 1 diabetes at an early age but did not realize the profound effect that diabetes would have on her life until she had a physical shortly before starting college. Despite her efforts to control her diabetes for the last 20 years, she unfortunately has lost her sight. In spite of the hardships that diabetes has imposed on her life, Ms. Fernandes has become an international tandem cycling champion and a recognized para-olympic athlete. We are very pleased to have her with us today. We will then hear from Gordon Jump, who most of you probably recognize from his role on the television series ``WKRP in Cincinnati.'' You might also, however, recognize him as the lonely but ever-ready Maytag repairman. In real life, however, Mr. Jump has type 2 diabetes, and he will give us his perspective of living with this disease. Now, the sports fans out there will undoubtedly recognize our next witness, William Fuller, who played in four pro bowls during his 13 years as an NFL defensive lineman. Mr. Fuller is a former board member of the Juvenile Diabetes Foundation, who first got involved with this cause after his father unfortunately died from diabetes-related illness. Mr. Fuller hosts several fund-raising events sponsored by the Juvenile Diabetes Foundation, including the ``Sack the Quarterback'' promotion. So we are very delighted to have all four of our witnesses here with us today. They span different ages, obviously. They have different experiences. And we really appreciate their willingness to come forward and help better educate the Subcommittee, and indeed the entire Senate, on the implications of living with diabetes. Now, as I explained to Dr. Gorden, pursuant to the Subcommittee rules, we do need to swear you in. At this point I would ask that you all stand and raise your right hands. [Witnesses sworn.] Senator Collins. Thank you. Ryan, since you are the youngest, you get to go first, so we will ask that you proceed with your testimony. TESTIMONY OF RYAN DINKGRAVE,\1\ LIVONIA, MICHIGAN, ON BEHALF OF THE JUVENILE DIABETES FOUNDATION Mr. Dinkgrave. Madam Chairman and Members of the Subcommittee, thank you for giving me the opportunity to testify this morning on behalf of the Juvenile Diabetes Foundation International. As is already stated, my name is Ryan Dinkgrave. I am 16 years old and a student at Stevenson High School. I hope to attend college at the University of Michigan and eventually find success in a career field which I enjoy. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Dinkgrave appears in the Appendix on page 62. --------------------------------------------------------------------------- I was diagnosed with juvenile or type 1 diabetes when I was in the fifth grade, just over 6 years ago. It was one of the scariest things that has ever happened to me. My pediatrician said that my constant thirst and exhaustion were because I had diabetes. I also lost weight, experienced frequent sluggishness and other common symptoms of diabetes. I had no clue what diabetes was, and I really didn't want to know, but we proceeded directly to the hospital. That day was the first of my 6-year experience of trying to live with diabetes. I was in the hospital for almost a week, and I left with no idea what to expect. It turned out that having diabetes meant my whole life was to be turned upside down and changed in every way. No longer could I just eat what I would like or when I would like, no longer could I really do anything without planning for so many possible situations related to having diabetes, such as low blood sugar that could lead to an insulin reaction or high blood sugar that could lead to severe health complications. I began trying to manage my diabetes with two shots a day, which eventually became three shots a day and then four. Along with the shots came blood glucose tests four, five, sometimes six times a day. These tests involve pricking my finger to draw a drop of blood. Along with these daily efforts came worries about what could happen if my blood sugars were not kept in good control: Heart problems, kidney problems, nerve damage, vision problems, blindness, amputations--the list seemed like an impossible thing to avoid. My life would certainly never be the same. Last November, after doing insulin injections for over 5 years, I switched to a more advanced type of insulin therapy called the insulin pump. This is a device that is about the size of a pager, which administers insulin through a tube that goes into my body and has to be moved to a new location every 2 days. While it has allowed me more freedom, better blood sugar control, and possibly a longer life, it is still not perfect and living with diabetes is still, at best, very difficult. Until there is a cure, nothing will satisfy those who struggle to live daily with this disease. A common misperception about diabetes is that one with diabetes is healthy. This is because people with diabetes often have no outwardly visible characteristics of the disease, especially teens and children with diabetes. There is no physical evidence of the organ damage and future health concerns of somebody who has diabetes. Look at any teenager or child with diabetes. They look just like anyone else their age. Put 100 kids in a line, and you cannot possibly pick out who has diabetes or who does not. It is because of this that many people do not realize the severity of diabetes and the urgency for a cure, until it is too late and complications of the disease have set in. I personally have had to struggle a lot with diabetes, both emotionally and physically. I have to worry about future health concerns, and every moment of every day I must be aware of my condition and treat it. I have had three seizures due to low blood sugar. I know that this scared me and my parents like never before with how serious and trying these events have been. I have done a lot to help spread out information and awareness on diabetes, and work with others, diabetics and doctors and what not, like myself. About 3\1/2\ years ago I started a Web site called ``The Family's Guide to Diabetes'' at diabetes.cbyc.com for children and teens with diabetes. It was created basically to fill what I thought was a need for a way for people with common situations to exchange information and experiences. Through the site, and through my speaking to doctors, families and others about diabetes, I have been able to exchange a lot of this information and learn about how others live with diabetes. Also, I have participated in JDF's Walk to Cure Diabetes for each of the past 5 years. In fact, this year my group, Team Ryan, raised a new high of $4,000 which will go to support curing diabetes through JDF's $75 million research budget. This past summer I was the Michigan representative for the JDF Children's Congress here in Washington, D.C. The JDF Children's Congress allowed 100 children and teens with diabetes to explain to Congress and the Nation how diabetes impacts us and the need for increased research funding for a cure. I learned at the Children's Congress about the Diabetes Research Working Group report that indicated there are many high-quality diabetes research projects that are not being conducted solely due to a lack of funding. On behalf of all the children and teens with diabetes, I urge you to ensure that this funding be made available so we can find a cure as quickly as possible. Thank you very much for allowing me the opportunity to testify, and I would be pleased to answer any questions. Senator Collins. Thank you very much, Ryan. Ms. Fernandes. TESTIMONY OF PAM FERNANDES,\1\ NEEDHAM, MASSACHUSETTS Ms. Fernandes. Good morning. My name is Pam Fernandes. I am from Needham, Massachusetts. Thank you for the opportunity to speak with you today about diabetes, a disease which plagues our Nation. Today some people will give you statistics relating to diabetes. These numbers will give you a sense of the overwhelming breadth of the problem. Through my story, I hope to give you a sense of the tragic depth of the problem. --------------------------------------------------------------------------- \1\ The prepared statement of Ms. Fernandes appears in the Appendix on page 65. --------------------------------------------------------------------------- Thirty-four years ago I was diagnosed with type 1 diabetes. At the age of 4, my understanding was quite simplistic: Two painful injections a day, urine tests, and no treats. Through my childhood and early adolescence I tried desperately to understand the disease that made me different from every other kid. When I was 18, at the very time in my life when options should have been endless, diabetes threw me a curve. I went to visit my eye doctor 2 weeks before leaving for college. He told me I had a few small hemorrhages, nothing to be worried about, but that I should see a specialist when I arrived in Boston. Two weeks after arriving in Boston, I got the news that I was going blind. The day I walked into that doctor's office began 8 of the most painful and difficult years of my life. After laser surgery and five eye operations, I was declared legally blind. I was just 21 years old. One week before my 22nd birthday, I started dialysis treatments. You see, diabetes had also affected my kidneys. I lived on a machine for 5 years, and although everyone said I was doing remarkably well with the treatments, I never felt worse in my life. I couldn't really imagine any kind of future with each day being so emotionally and physically painful. After more than 30 operations and two episodes of respiratory arrest, I made a life-changing decision. In 1987 I received a kidney transplant. The first year was difficult, but soon I rediscovered the Pam that was vibrant, alive and tenacious. About the time life began looking up for me, my family was hit with an unthinkable tragedy. My oldest brother, Mark, died from complications of his diabetes. He also had kidney disease, which led to his failing health. One of the most difficult things about Mark's death was watching my parents cope with the loss of a child. Diabetes had taken the life of a 32-year-old man who had a wife and a young girl. In 1992 I was invited to ride on the back of a tandem bicycle. Little did I realize that that would both change my life and open doors that I never dreamed imaginable. I rode recreationally for about a year to stay fit and have fun. I got involved with American Diabetes Association Tour de Cures, bike rides designed to raise money to support diabetes education and research. I am very happy to have been invited to be the national spokesperson for the American Diabetes Association Tour de Cures for the next 2 years. Bike racing entered my life in 1993. I attended a camp for cyclists with disabilities held at the U.S. Olympic Training Center. This was one of the most empowering weeks of my life, and I decided to give bike racing a try. In 1994 I won a silver medal at the World Championships for Disabled Cyclists in Belgium. At the 1996 Atlanta Paralympic Games I won a bronze medal. I have earned over 12 national championship titles. I was surprised to find out that I was the only diabetic athlete on the disabled cycling team. I also learned that I was the only transplant recipient to ever have competed at the Paralympic Games. As if these recognitions were not enough, I have also been recognized through many awards, including being named U.S. Olympic Committee Athlete of the Year. I am, in many regards, a very lucky girl. This disease hasn't been kind to me, but so far I have come out ahead. I am a living example of how far we have come with research, by the mere fact that I am here talking with you today and that I am doing what I am doing. I am also a very sad reminder of how far we have yet to go. My story speaks well to the power of the human spirit, but how many setbacks can one spirit endure? Unfortunately, I am not the rule but the exception. Many people with diabetes don't have the determination, the desire, the knowledge, the opportunity or the family support to succeed as I have. That is why it is so important for you as our Congressmen to understand our disease and to help us by supporting the research that will help us find better treatment options and ultimately the cure. I learned some very poignant lessons my first few trips to Washington. I learned the enormous responsibility that our Congress has as it relates to our Nation's health. I also learned that there is nothing between me and the cure to my disease but money. We have no lack of researchers. We have no lack of desire. What we have is a lack of money. Diabetes must become a national priority. Right now there are over 16 million people in the United States with diabetes. In the coming years that number will go up because diabetes isn't going away. With the diligence of the Diabetes Research Working Group, we have identified extraordinary scientific opportunities. We must find the means to support this research. We must find that $827 million. Diabetes and its complications are a financial drain on our country, not to mention the human toll that it takes. My mom and I made a pact when my brother Mark died. I told her that I would never give up. She knew that I was a fighter and a survivor. But the sad fact is that I probably will succumb to this disease, because like it or not, it has got a pretty good track record of shortening people's lives. For as long as I am able, I promise that I will do what I can to stop diabetes. Please make that same commitment today. We need your support, your understanding and your wisdom. Together we can fight this disease, diabetes. Together we can win the battle, but it will take all of us to do what we can. Thank you for your time and interest in our disease. Senator Collins. Thank you very much for your testimony. Mr. Jump. TESTIMONY OF GORDON JUMP,\1\ COTO DE CAZA, CALIFORNIA Mr. Jump. Madam Chairman, Members of your Subcommittee, my thanks for the opportunity to address you. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Jump appears in the Appendix on page 68. --------------------------------------------------------------------------- About 20 years ago I found that I am a type 2 diabetic. For 5 years I lived in a state of denial. Sooner or later, though, you have to come to grips with the fact that you have a chronic illness. When you finally acquire the gumption to take advantage of the educational programs offered by many of the hospitals, you will encounter a term that you do not usually associate with disease, and the term is ``manage.'' You must learn to manage your disease. Managing diabetes, a disease with few overt signs and symptoms, is not really an easy task. Self-discipline, almost a dirty word today, is the most important part of disease management for the diabetic. Carefully monitoring diet, exercise, body changes, medication, requires a diligence that most of us just simply do not possess. In order to simply survive we have to spend money, and lots of it, to keep the disease under control. We discover that diabetes is not just a single disease to be treated. Diabetes affects the cardiovascular system, the nervous system, neuropathy, affects your feet, your legs, and ultimately other parts of your body. Your eyes can be affected to the point of blindness. Lack of circulation in your limbs can cause you to require amputation. You are in a constant struggle with life and death, actually. In the case of type 2 diabetes, onset is usually at the time of life when the person is most productive. This is also the time when you are under the most stress: Climbing the corporate ladder, struggling with teenagers at home, and going through divorce or being downsized, maybe even going through a midlife crisis, whatever that is. It is rather like the chicken and the egg thing: Which comes first, the stress or the diabetes? The American Diabetes Association has done a tremendous job in bringing the standard of awareness to a much higher level, but I am sure they would agree that the standard of awareness is not nearly high enough. The ADA has also provided tremendous support to physicians in providing educational services on the disease and its management to their patients. In the 20 years since I was diagnosed, I have suffered a number of health problems, several of which can be directly attributed to diabetes. For the first 8 years or 10 years of my condition, I simply had to take pills, watch my diet, and saw my endocrinologist when I felt I should, which in the case of most diabetics was never enough. By the time I had acquired enough sense to seriously consider doing something to maintain my health, my health was already all bad. I had high blood pressure, four-digit triglycerides, cholesterol numbers that would scare even an actor. Not only did I go on insulin, but I needed a lot of other medications: Pills for my heart, high blood pressure, triglycerides, cholesterol, digestion, and it goes on and on. Sometimes a severe and sudden change in someone's eyes gives a physician a clue that diabetes may be the ultimate diagnosis for an individual. I have worn glasses for many years and often had to have my prescription changed. It wasn't too long ago I woke one morning and I realized that I was seeing double; was not anything that I had had to drink or eat. After a number of tests had been made to assess the situation, I was finally fitted with glasses that made it possible for me to function. It was a frightening time for me, not knowing whether my sight would ever be restored to single vision again. Vision problems, including blindness, is another of the complications of diabetes. This past June, I underwent angioplasty. The triglycerides and the cholesterol, all spoken of as being part of diabetes, had finally spoken. My blocked artery was discovered much the same way my diabetes was discovered, during a physical exam administered during the month of May. It was not the best time for me to have a procedure that could turn into a situation that might incapacitate me for several days, because my daughter was about to get married in the month of June. The angiogram disclosed an artery that was approximately 95 percent occluded. At the very least it would require a stint or angioplasty, and at the worst, bypass surgery. Fortunately, while the artery's shape and placement did not allow for the emplacement of a stint, an angioplasty seems to have been successful. Being afflicted with diabetes is not something that I would wish on my worst enemy. How much money will be needed for basic research to conquer this insidious disease, I really do not know. How much is the disease itself costing the country in the form of Medicare, Medicaid, disability and other county, State and Federal programs? I really do not know. I calculated what I thought would be the cost of the most basic diabetic supplies for an insulin-dependent type 2 diabetic for 1 month. Assuming checking the blood sugar only twice a day, using one test strip each time, it would run about $1.34 per day. Two sterile alcohol swabs to help you with that, 16 cents a day. And 20 units per day of insulin, and that is very, very minimal, $4.20 daily. The cost of 1 month's basic supplies would be somewhere around $184.20. Now, this figure also assumes that no other medications are required, and it does not account for doctor's visits, transportation, or the other things, the miscellaneous things, that are involved with the disease. I calculated that the cost of my medications--that is not including doctor, hospital, extra glasses, or other devices--if I had no insurance, the cost for 1 month would be around $733.20. Even with insurance, I manage to pay more than $200 per month. The standard co-pay for a prescription is $10. However, because of the price of some medications, the co-pay can be as much as eight times that amount. For example, one medication without insurance help would cost $149.50 a month, and another is $111.82 for 1 month's supply. I think about the monetary cost of this disease and wonder how people who are struggling to live on Social Security can possibly do an adequate job of caring for themselves, even with Medicare. I know there are other programs that help some, but the gap is still way too wide. If it was one disease that remained as one, perhaps it would be sufficient to allow the drug companies to take their time to seek out a cure. Diabetes takes its toll in the day-to-day wear and tear that it afflicts on the human body in the form of heart disease, amputations caused by wounds that won't heal, eyes that lose their sight, financial burdens, and sundry other complications. The final blow it administers is the worst of all: A parent with type 2 diabetes finds out that his or her child has been diagnosed with the disease, and the cycle begins all over again. I say let us break that cycle. Let us put type 2 diabetes out to pasture with smallpox, polio, whooping cough, and dyptheria. And let us find the research necessary and fund the research necessary to find a cure. And I ask Congress to make that money available so that can be accomplished. My thanks to you, Senator, and to those other members of the Senate who see the insidiousness of the disease, know the importance of its cure for the financial well-being of our Nation, and are willing to do something about it. Thank you. Senator Collins. Thank you, Mr. Jump. Mr. Fuller. TESTIMONY OF WILLIAM H. FULLER, JR.,\1\ VIRGINIA BEACH, VIRGINIA Mr. Fuller. Chairman Collins and Members of the Subcommittee, thank you for inviting me to testify today regarding diabetes research, an issue I care deeply about. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Fuller appears in the Appendix on page 73. --------------------------------------------------------------------------- In 1991, I was in my fourth year of NFL football as a defensive lineman with the Houston Oilers. After playing spot duty for the first years, I was finally getting my long overdue chance at being a starter. Having played 2 years in the old U.S. Football League and 3 years with the Oilers, I had already made more money than I could ever imagine. This success had enabled me to buy my mother and father their first house, complete with a satellite dish so that they could watch me play anywhere in the United States, this after living in apartments our entire life. I was the first person in the Fuller family lineage to graduate from college. I had been married for 5 years, and had a beautiful wife and two young daughters. It should have been one of the better periods in my football career, or life for that matter, but that was not the case, for I was seriously considering retirement. You see, back in my home town of Chesapeake, Virginia, a totally different story was unfolding. The people I owed the most gratitude for my success were suffering, suffering because of diabetes. My father had type 2 diabetes. His diabetes had already caused him to have a leg amputated while I was in college. It also caused his kidneys to fail, and he had to be hooked to a dialysis machine 3 days a week for 3 hours each visit. And now, to make matters worse, he was losing his eyesight. At 6 feet 3 and 260 pounds, I knew it was getting harder and harder for my mother to take care of him. She also took care of my sister, who cannot hear as the result of a bout with spinal meningitis when she was a baby. Until I left for college on a football scholarship, it had always just been the four of us. My wife suggested I get a nurse to help my mother take care of him, but mom kept saying they were fine and no need for me to worry. She promised to let me know if things got too tough, but on a recent trip home a neighbor informed me that my father had fallen down in the bathroom and my mother had to call the neighbor to help get him up. I told my father my thoughts of quitting football so I could return home and help out. If he could have gotten up and punched me, I think he would have. I remember it as being one of the few times I had ever seen my father cry. He told me how proud he was of the man I had become, and no matter what happened, to promise not to quit because of his situation. He said that my quitting football would do more harm to him than diabetes ever could. I did not believe that, but we decided to get some help for my mother, and I promised not to quit, a promise that was made even tougher because of the Oilers' insistence that players live and train in Houston year round. It was during that same time that I met a gentleman named Milton Slocum at a charity event. He informed me of his business as a publicist and marketing agent for several of the Houston Rockets. We agreed to meet the next day. We met, and basically I told him the story I just told you. When he asked me specific questions about diabetes, I honestly could not answer them. All I knew, that it was a horrible disease that was wreaking havoc on my father, and it had something to do with the fact that his body was not producing enough insulin. The next week Milton scheduled a meeting with the Juvenile Diabetes Foundation. It was a meeting that would forever change my life. I later served 6 years on JDF's International Board of Directors, and currently serve on its Board of Chancellors. I walked into JDF's office as a helpless and hopeless young man with a lot of questions. I walked out with many answers to my basic questions, but more importantly, I walked out with hope, hope that research would lead to a cure. Through my annual celebrity golf classic and the ``Sack the Quarterback'' promotion, we have raised over $1 million toward this important research. I have learned a lot about this disease. I now know that there are over 60 million people with diabetes, and that many of them are children. To watch my father, my hero, suffer and eventually succumb to diabetes was very tough, but I cannot imagine the pain if this disease were to attack one of my four daughters. However, over the years I have met many parents that are dealing with this nightmare on a daily basis. I cannot imagine having to give my 2-year-old daughter an insulin injection, or having to realize the possibilities of blindness, amputation, or diabetic comas that she or any of my daughters could face for the rest of their lives. In almost 20 years of playing college and pro football, I have learned a lot about teamwork. I sincerely believe that the team of researchers at the National Institutes of Health, JDF and other organizations are on the right track to find a cure. I am proud to be part of that team. Every team needs leaders, and Congress, and the NIH, if they provide the funding to support all diabetes research opportunities, have the capability of leading the way to a cure. We are ever so close to our Super Bowl--that is a cure for diabetes. I thank you for your time, and may God bless you all. Senator Collins. Thank you very much, Mr. Fuller. I must say I had a series of questions to ask each of you, but I think your testimony speaks for itself. You have put the human face on this devastating disease. Your testimony is so eloquent and so moving that anything I could ask you would be superfluous. It is why I wanted Dr. Gorden to stay. It is why this report is so critical, because it says ``conquering diabetes.'' It is why the increased research is just so vital. Your stories are so moving, your courage so inspirational, that I just want to pledge to you that I accept Ms. Fernandes' challenge to fight for a cure for this disease and to keep fighting until we have achieved that goal. Ryan, I want to say to you how much I appreciate the efforts that you are making to reach out to other kids and to teens with diabetes through your Web site. You are absolutely right that most people do not understand how serious this disease is. And that is why all of your testimony is so important, because you have each eloquently described either your own struggle, or in the case of Mr. Fuller, his father's struggle with this devastating disease. You have put the human face on it. We can talk about the statistics, we can look at the charts, but until we hear from you first-hand and what it has meant to your lives and your family's lives, that is what we need to provide the momentum for the cure. I just want to thank each of you for your eloquence, for speaking out, for caring enough, for your involvement, and for being here today. You are why we are here, and I just want to assure you of my personal commitment to keep up the fight. So I accept your challenge, Ms. Fernandes, and again, thank you for your courage and thank you for speaking out. Thank you for your good work. I would now like to call our final panel of witnesses this morning, and I am sure our final panel, which are distinguished scientists, have also been moved by what they have just heard, and if anything will redouble their efforts. They are all such leaders in their fields. Dr. Ronald Kahn is the former chairman of the congressionally mandated Diabetes Research Working Group. He was the chairman of the group that produced this very important report. He is also executive vice president and director at the world-renowned Joslin Diabetes Center in Boston. Dr. Edward Leiter is the senior staff scientist at The Jackson Laboratory in Bar Harbor, Maine. Dr. Leiter took me around the lab a few months ago and told me of the very exciting research. I became aware of Jackson Lab's role when I was visiting the Juvenile Diabetes Center, Research Center, at Harvard Medical School earlier this year, and all the mice they were using of course came from Jackson Lab. Finally, we have Dr. Jeffrey A. Bluestone, who is the director of the Ben May Institute for Cancer Research at the University of Chicago in Chicago, Illinois. I am very pleased to have three such distinguished researchers and scientists who really are on the cutting edge of diabetes research with us today. As I have explained previously, our rules do require that everybody be sworn in. Makes more sense when we are having an investigative Subcommittee, where we are worried that people won't tell the truth, but we do have to apply it across the board, so if you would, please stand. [Witnesses sworn.] Senator Collins. Thank you. Dr. Kahn, I would like to start with you, and again I want to welcome all of you to the Subcommittee. TESTIMONY OF C. RONALD KAHN, M.D.,\1\ EXECUTIVE VICE PRESIDENT AND DIRECTOR, JOSLIN DIABETES CENTER, BOSTON, MASSACHUSETTS, AND FORMER CHAIRMAN, DIABETES RESEARCH WORKING GROUP Dr. Kahn. Thank you, Chairman Collins, and I also want to thank you personally and this Senate Subcommittee for giving me a chance to present this report of the Diabetes Research Working Group to you today. As you are aware, the Diabetes Research Working Group or DRWG, as we came to call it, was created in response to a request by the House and the Senate to evaluate the current state of diabetes research in the United States and to develop a strategic plan for the Nation as to how best to proceed making progress against this disease. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Kahn with attached charts appears in the Appendix on page 75. --------------------------------------------------------------------------- The DRWG consisted of 16 members representing the scientific and medical community, the JDF, the ADA, minority populations that are disproportionately affected, and others who have interest in this disease. We had tremendous support from the NIH, in particular from NIDDK, from Dr. Gorden's office and Carol Feld, who is here at these hearings, and from a number of other individuals that all deserve a lot of credit and thanks. Now, what is diabetes, and why was it so important that this Diabetes Research Working Group was deemed necessary? As you have already stated, diabetes is a very complex disease. Furthermore, it is not a single disease but rather a group of diseases which affect a large number of people. The two major forms of diabetes, type 1, the insulin- dependent form of diabetes, which used to be called the juvenile-onset form and type 2, the adult onset form, often called non-insulin-dependent diabetes, although it too may require insulin therapy. These two forms affect 16 million Americans, as has been mentioned already. It is estimated that over 700,000 people, mostly children and young adults, have type 1 diabetes. And as individuals age, diabetes becomes even more common. In fact, if we all live to be 80--and we all hope to live to be 80--17 percent of the people in this room will have diabetes. As a result of these two forces, the type 1 and the type 2, about 800,000 new cases of diabetes are diagnosed each year. In addition, there are many other forms of diabetes. Some are rare, but some are quite common. For example, gestational diabetes is a form of diabetes that occurs during pregnancy and affects over 5 percent of all women in the United States who become pregnant. As we have already also heard, diabetes spares no one. We have heard from Ryan, and my neighbor Avi Robbins who is about the same age. We have heard in the House and in the Congress from Nicole Johnson, last year's Miss America. We know it from our parents and our grandparents and our grandchildren, from one coast to the other. Everyone is at risk. The risk is particularly high in minority populations of the United States. African Americans, Hispanics, Native Americans and Asian Americans not only represent some of the fastest growing segments of our population, but they are particularly vulnerable to diabetes and its complications. Among these groups, the Pima Indians of Arizona have the highest incidence of diabetes in the world. Over 50 percent of the adults have diabetes in that indian tribe. Not only does living with diabetes present many day-to-day challenges, but as has already been said, affects virtually every tissue of the body with long-term and severe damage. Diabetic eye disease is the most common cause of blindness in working age adults. Diabetic kidney disease accounts for 42 percent of end-stage renal disease, that is, patients requiring dialysis or transplantation. It is the fastest growing cause of end-stage renal disease. Stroke and heart disease are increased two to four times, as you have already said yourself, and this is especially increased in women who normally are protected from these vascular problems, at least in the premenopausal age group. Diabetes affects the nervous system, leading to impaired sensation, pain, and slow digestion, impotence and many other problems. The rate of congenital malformations in offspring of diabetic women is increased three- to four-fold, and more than half of the lower limb amputations in the United States are secondary to diabetes. As has already been said also, diabetes is the sixth leading cause of death in the United States, but in fact in some of these minority populations it is the third leading cause of death. Now, as you have already shown, and one of the surprising findings even to the members of the DRWG is that despite all of our knowledge and despite all of our efforts, since 1980 the age-adjusted death rate due to diabetes has increased by 30 percent, while the death rate from other common diseases such as stroke and cardiovascular disease has fallen. Of course these are only statistics. We have already heard from a number of individuals today about the very personal impact of this disease. In our report we had five personal profiles, including one from Pam Fernandes, who presented today. I am sad to tell you that one of the individuals who was discussed in our report, Jerrold Weinberg of Detroit, actually passed away from the time the report was being prepared to the time we were able to present. He died at the age of 39 from complications of this disease. The economic impact of diabetes is also staggering. The cost of diabetes to the Nation has been estimated at $105 billion annually, and some estimates have gone as high as $130 billion. Somewhere between 10 and 14 percent of all U.S. health care dollars are spent for people with diabetes. One of every four Medicare dollars pays for health care of people with diabetes. Next chart, please. Another striking finding of the DRWG was that while health care costs for each person in the United States affected with diabetes average $6,560 annually, the current investment in diabetes research is only about $30 per person affected per year. That is, less than one-half of 1 percent of the cost of the disease is invested in R&D in an attempt to reduce the burden caused by diabetes. This is a very small investment for a disease that affects 6 to 7 percent of the population and accounts for 10 to 14 percent of all health care dollars. With these facts in mind, the strategic plan created by the Diabetes Research Working Group had multiple goals. We felt that it was important to understand the causes of diabetes and the causes of its complications; to develop methods to prevent and treat diabetes, and to prevent and treat diabetic complications, methods to reduce the impact of diabetes in minority populations; and to develop the research infrastructure and to train investigators to do the necessary research to achieve these goals; and of course, very importantly, to translate these research findings into clinical practice. In developing an approach to this plan, I took some advice that was given to me by Lee Iacocca, who is a strong supporter of diabetes research through his own foundation and supports diabetes research at the Joslin as well. And he said, ``Just imagine you are in the year 2010, and you would like to look back and see what you have accomplished in the area of diabetes. Then, given these goals, what would you have to do over the next decade to at least have some chance of accomplishing them?'' And so this was the challenge to the committee, and this is what led to this 140-page Research Strategic Plan that you have before you today. There are three major components of the DRWG's strategic plan: Extraordinary opportunities, these were areas that we viewed as rapidly expanding and important areas of research, where increased investment or development of new approaches would significantly speed research. Special needs for special problems was an area that we felt was equally important, but these were more focused areas of research, usually targeted to specific populations or specific complications or some cases specific methodological approaches. And then, finally, resources and infrastructural needs. This was, of course, the plan for increasing research manpower and technology, as well as the infrastructural elements required for diabetes research. In this plan, all in all, there are 88 recommendations in 16 different categories, and I would just like to briefly talk about a couple of these today. Perhaps one of the most exciting areas in all of research today is in the area of genetics, and the genetics of diabetes and its complications. If we identify the genes for diabetes and its complications, we may someday be able to predict and prevent the disease. Understanding the genetics will also give us the opportunity to develop new therapies that are directed at the true, central problem of the disease. The DRWG proposes several initiatives in the area of genetics, including the creation of a national consortium for the study of the genetics of diabetes. One of the goals of this consortium would be to develop a diabetes DNA chip. In fact, I brought this actual DNA chip to show you. The little square in the center of this black holder is the DNA chip that we are using in my laboratory and is being used in other laboratories to try to identify some of the genes that might be altered in diabetes. We believe that with the proper investment in research, within a decade a diabetes-specific chip could be developed, that when exposed to DNA from a few drops of blood, would tell us who is likely to develop diabetes, which of the diabetic patients are most likely to develop which complications, and perhaps even who would respond best to each specific treatment approach. A second area that we will hear I am sure more about from Dr. Bluestone is the area of autoimmunity and the beta cell. This holds the key to type 1 diabetes, since type 1 diabetes is an autoimmune disease that destroys the insulin-producing beta cells. Important progress has been made in this area over the past several years, including identifying some of the genes involved in predisposing to type 1 diabetes, some of the components of the beta cell that are attacked; developing markers for detection of pre-diabetes; and demonstrating the critical importance of tight glucose control for reducing diabetes complications. But there remain many challenges which are critical if we are to conquer this disease, and in the DRWG report we describe a program to intensify research to understand the immunologic basis of type 1 diabetes; to develop optimal strategies for blocking the immune destruction; for expanding research in the area of transplantation as therapy, which will require solving critical issues such as, where do we get enough islet cells to treat the hundreds of thousands, or perhaps eventually millions, of people who could benefit from this treatment; and how do we protect these transplanted cells from immunologic rejection? Other extraordinary opportunities that are listed in the report include an area of basic research called cell signaling and cell communication. This is a very important area, because we believe that in this area will be the keys for understanding type 2 diabetes; and type 2 diabetes, after all, does account for 90 percent of all of the patients with this disease. Obesity, another critical area of extraordinary opportunities. Research in animal models, such as has been done at The Jackson Laboratory and in other laboratories, has pointed the way to the great opportunities here that need to be approached in our studies for humans with this disease. And, finally, the area of clinical research and clinical trials which must be applied to develop evidence-based medicine to approach this disease. The DRWG has also made special recommendations, in our special needs for special problems area, regarding the eye, kidney and nerve complications as well as the cardiovascular complications, which is the major killer of people with diabetes. In these areas we must define exactly how and why does diabetes enhance the atherosclerotic process or these other vascular problems. Why do women with diabetes tend to be at special risk and lose their vascular protection? What are the factors that occur in diabetic patients, that lead them to be at increased risk of dying after a heart attack, and how can we develop therapies to enhance their survival? And can we develop better specific, noninvasive techniques to identify the presence of diabetic complications, predict their progression, and assess their response to therapy? We also describe basic and clinical research programs to better understand the impact of diabetes in the young, in the old, in women, and in minority populations. As I have already indicated, the current investment in diabetes research is small, and indeed far too small to provide the resources needed to begin to address the research plan. As requested by Congress, therefore, the DRWG has developed budgetary recommendations to accompany this plan. You will see that the recommendations call for a 5-year step-up in the research budget for diabetes, from the current level of about $443 million to, as you have pointed out, $827 million for the year 2000, and actually rising to $1.6 billion by the year 2004. Let me point out to this Subcommittee and to this group that these numbers were not arbitrarily chosen. They were based on a planning process, a detailed planning process that took 15 months, and we believe describe what is realistically needed to bring diabetes research to a point where there would be at least a reasonable chance that we could accomplish a number of the goals that we have set forth over the next 10 years. In the full report, this detailed budget is outlined in a project-by- project and institute-by-institute manner. Finally, I would like to point out that the members of the Diabetes Research Working Group do not believe that diabetes research should necessarily be funded by taking resources from other important biomedical research needs. We understand the problems that NIH faces. We are very supportive of NIH, the Director of NIH, Dr. Varmus, the Director of NIDDK, Dr. Gorden, and we recognize the many challenges that must be faced in utilizing their precious resources. But we would like to use the analogy that like the military, which must be prepared to fight a battle on at least two fronts, the NIH and the biomedical research community must be prepared to fight a battle of human disease, not just on two fronts, but on many fronts at once, and this will require a significant investment both immediately and in the long term. The DRWG is convinced that there is both great urgency and unprecedented opportunities in diabetes research. We are convinced that taking action now will save thousands of men and women and children from severe consequences of diabetes. We have done the first part of the job by developing the report, and we applaud and are delighted by the support of the Senate and its recommendation to support this. We now ask the U.S. Government and the NIH to give its continuing support to allow us to do the research that will be required to conquer this dread disease. Thank you. Senator Collins. Thank you, Dr. Kahn. Dr. Leiter. TESTIMONY OF EDWARD H. LEITER, PH.D.,\1\ SENIOR STAFF SCIENTIST, THE JACKSON LABORATORY, BAR HARBOR, MAINE Mr. Leiter. Madam Chairman, I wish to begin by commending you and the other Senator co-sponsors of the recently passed sense of the Senate resolution calling to the attention of the American people the impact that diabetes has on our population and urging increased support for diabetes research, education and early treatment. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Leiter appears in the Appendix on page 86. --------------------------------------------------------------------------- I am a senior staff scientist at The Jackson Laboratory, a world center for mammalian genetics, and my research focus has been mouse genetic models of both type 1, insulin dependent, and type 2, non-insulin dependent, diabetes. Now, the fact that there are different forms of diabetes underscores the genetic complexity of the diseases, but there is something in common, and unfortunately we have heard about that commonality. Those are the complications of kidney failure, blindness, heart disease and stroke, and amputations. I have a personal family reason for being interested in both type 1 and type 2 diabetes. My grandfather had type 2 diabetes and my uncle, Frank Black of Los Angeles, California, has been struggling valiantly with his type 1 diabetes since first diagnosis in 1942. So it is concern for my uncle, for the millions of Americans who now fight with their diabetes, and for those Americans that will develop diabetes, that leads me to give you my comments. We now know that most cases of type 1 diabetes in humans represents an autoimmune disease, wherein a rogue immune system turns against the body in which it resides. We have an excellent mouse model, the NOD mouse, for autoimmune insulin dependent diabetes. One of the most important lessons we have learned from the NOD mouse is that autoimmune diabetes is a preventable disease. This finding, along with similar findings in another animal model, provided the impetus for NIH to initiate clinical trials to prevent type 1 diabetes from developing in young adults deemed at high risk. One of the most exciting recent developments in my laboratory comes from the close relative of the NOD mouse. Like the NOD mouse, this relative seems to have just the right genetic program to develop type 1 diabetes. It doesn't. Why? It seems that the insulin-producing beta cells of this mouse are unusually resistant to immune-mediated injury. With support from the American Diabetes Association and the Juvenile Diabetes Foundation, we are working very hard to try and decipher or understand the factor that is protecting these beta cells. We hope that these findings can be extrapolated to make human islets more resistant to damage by a rogue immune system. Of equal importance in my research are the mouse models of obesity in type 2 diabetes that I am developing. Such new models are of tremendous importance in the testing of pharmaceutical compounds to be used in the treatment of human type 2 diabetes. For example, these mice are helping us identify genetic targets that respond favorably to a given pharmaceutical compound, as well as identifying the genetic makeup of individuals that would suffer adverse side effects if they were treated with a comparable anti-diabetes drug. I would like to add some thoughts about the recommendations made to Congress by the Diabetes Research Working Group. Obviously, as a recipient of NIH funding to do my own diabetes research, and having participated in the development of the DRWG recommendations, I am biased in my hope that the recommendations could be implemented by the NIH. Although considerably more NIH funds have been designated for diabetes-related research in the past year or two than ever before, research dollars that are allocated are still inadequate to fund all the meritorious investigator-proposed grant applications in the areas identified by the Diabetes Research Working Group. I have personally served in NIH peer review panels evaluating diabetes research, and have observed that the competition for grant funding today is so stringent that many scientific avenues that could be explored are not being explored. Indeed, if the discoverers of insulin, Drs. Frederick Banting and Charles Best, were to apply for an NIH grant today, providing only their interesting hypothesis that the pancreas made a substance that might control blood sugar, I am fairly convinced that their application would be turned down. Why? The answer is that with NIH's rather limited resources devoted to diabetes research, only those investigators receive funding who can demonstrate with preliminary studies that the hypothesis they are proposing to test is correct. This review process assures the Congress and the American taxpayers that their monies are being wisely spent by the NIH. However, it also means that the process of scientific discovery, which often moves by trial and error, and sometimes even serendipity, on the road to getting an ``eureka,'' is not being promoted to its fullest extent. Thus, progress on the path to better therapies and an eventual prevention of diabetes is not as rapid as it might be if all the Diabetes Research Working Group recommendations could be implemented. So, in closing, let me thank the Subcommittee and especially the Senator from my own State of Maine, Senator Collins, for inviting my comments. We are now in an unparalleled age of discovery in molecular genetics in both mice and in humans. The Human Genome Project, which the Congress has so wisely supported, will provide a genetic blueprint on which a massive structure of new knowledge will be built. This new knowledge will certainly contain the key to new therapies not only to control diabetes but more importantly, as Dr. Kahn has suggested, to identify individuals at risk to develop this devastating disease, and thereby permit interventions to prevent diabetes from happening. This is a reality now in my mouse models. Let us work to make it a reality in the human family as well. Senator Collins. Thank you very much, Dr. Leiter. I notice that the other Senator from Michigan, Senator Abraham, who has been a leader in the fight against diabetes, has also arrived, and I wanted to give the Senator the chance to either join us at the dias or to make any statement if he would like. Senator Abraham. I don't think it would hurt to sit here. Senator Collins. That would be great. Senator Abraham was a cosponsor of an amendment that I offered last week to the Labor-HHS bill, supporting the recommendations for $827 million in funding by the Working Group, and we have worked very closely on diabetes research issues. So I asked him if he would like to join us today, and I appreciate the fact that you have been able to stop by. OPENING STATEMENT OF SENATOR SPENCER ABRAHAM, A U.S SENATOR FROM THE STATE OF MICHIGAN Senator Abraham. Senator Collins, thank you very much, both for inviting me and for giving me a moment. I will not detract too long from the panel's efforts because we really want to hear from experts at these events. We had a hearing in my committee, or actually a markup on a bill, downstairs in the Judiciary Committee, so I couldn't be here as early as I had wanted and I have to head on back, but I did want to just congratulate you and thank you for the leadership you have demonstrated on these issues in our State as well as the other States. We have obviously a lot of folks who are in various ways incapacitated by diabetes. In our own family, both my wife's mother and father are diabetics who take regular insulin injection, so it is not an issue that doesn't have its impact even on us here in the Senate. And so I just want to thank you for the leadership. I fully support the efforts you have engaged in to try to both draw more attention to this disease, as well as to try to focus more of the Federal Government's efforts on trying to combat it. We appreciate all who have been part of this. Of course, we have a Michigan witness. I missed his testimony, but I had a chance to say ``hi'' to Ryan, and I want to welcome him and his family to the Senate. We appreciate having our constituents down to participate, but in particular when they bring important messages like he has today. So I just thank you very much, and I will let you return to the hearing, but I really appreciate very much an opportunity to speak out in support of your efforts. The prepared statement of Senator Abraham follows: PREPARED STATEMENT OF SENATOR ABRAHAM Madam Chair, I am proud to speak today on the importance of funding for diabetes research. Diabetes affects the lives of 15.7 million Americans, with approximately 2,200 newly diagnosed cases a day. High levels of funding are vital in developing a cure for this disease, which is why I strongly support an increase of 45 percent in funding within the Fiscal Year 2000 NIH budget for diabetes research, bringing funding levels to a total of $827 million. Diabetes affects almost every aspect of daily life. Imagine having your schedule being dictated by a regime of specialized diet, blood sugar checks, and insulin shots. Now, imagine being a kid and having to endure the countless doctors visits, injections, and tests. Or, not being able to attend a sleep-over, play a sport, or even enjoy the Halloween candies passed out during class. Imagine, instead of enjoying the freedom and spontaneity of being a kid, having your life revolve around a disease. This year, I was proud to be a Honorary Co-Chair for the JDF Children's Congress. The JDF is dedicated to discovering a cure for diabetes and the accompanying complications through the support of medical research. The Children's Congress provided a way for kids with diabetes to come to Washington and not only get an opportunity to meet their peers, but to educate their Senators and Representatives about coping with this disease. Our children face this disease with a courage beyond their years, but it is our responsibility to make sure that someday they won't have to. Today we have the privilege of hearing the testimony of a young constituent of mine, and one of this year's delegates of the Children's Congress. Ryan Dinkgrave is only 16 years old but has lived with diabetes since the fifth garde. I would like to take this opportunity to commend Ryan for his achievements in promoting diabetes awareness. He has created a Web site called the ``Families Guide to Diabetes'' for families to learn about coping with the disease. In addition, during this year's Juvenile Diabetes Foundation's (JDF) Walk to Cure Diabetes, Ryan's group, ``Team Ryan'' raised an event-record $4,000. All of us can learn from Ryan's courage and dedication. It is vital that we continue to fund diabetes research so we can someday find a way to cure this debilitating disease. I want to commend Senator Collins for her work to educate government and the public about this disease and the need for increased funding. I was proud to vote for her amendment to the Labor, Health and Human Services, Education appropriations bill, which calls upon Congress to raise awareness of the devastating impact of diabetes and instructs NIH to increase funding levels to that which has been recommended by the Congressionally-mandated Diabetes Research Working Group. Her amendment, which passed overwhelmingly, demonstrates, beyond a shadow of a doubt, the strong commitment in the Senate to finding a cure for diabetes and improving the lives of those affected by this disease. Senator Collins. Thank you, and thank you for your support in this area. I want to let you know that Ryan did a terrific job. You can be very proud of him and the efforts that he is making. Senator Abraham. Thank you. Senator Collins. Thank you. Dr. Bluestone, if you would proceed. TESTIMONY OF JEFFREY A. BLUESTONE, PH.D.,\1\ DIRECTOR, BEN MAY INSTITUTE FOR CANCER RESEARCH, UNIVERSITY OF CHICAGO, CHICAGO, ILLINOIS Mr. Bluestone. Good morning, Chairman Collins. My name is Jeffrey Bluestone. I am the Chairman of the Committee on Immunology at the University of Chicago, and also the Director of the Juvenile Diabetes Foundation Islet Transplant Center at the University of Chicago and University of Minnesota. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Bluestone appears in the Appendix on page 89. --------------------------------------------------------------------------- But I am addressing you today mostly as a Ph.D. basic scientist at the University of Chicago, on behalf of myself and other scientists, both basic and clinical colleagues of mine, all of us in continued pursuit for the cure for diabetes and other debilitating autoimmune diseases. All of these diseases depend very much on the Federal Government's support and your efforts and others for the basic and clinical research funds that we use. In my short presentation, I hope to impart to you my personal sense of optimism. I believe we are really on the precipice of making dramatic changes in the way we treat autoimmune diseases and diabetes, and with your help I feel that we have a chance of turning the corner quickly to fight these autoimmune diseases such as type 1 diabetes. I thought I might share with you some of my own research and why I think that we are indeed at a time to be very optimistic. My laboratory has focused for a number of years on the basic processes that determine why immune cells respond or don't respond to tissues, self tissues, foreign bacteria, or viruses. We have used organ transplantation as a model to try to understand how to reeducate, train the immune system not to recognize self tissue and not to recognize transplants of kidneys, livers, and most prominently in our recent research, islet cells from other individuals. What we have learned in the last 10 years, quite dramatically actually, is that type 1 diabetes is indeed an autoimmune disease, a disease caused by the T cells in the body's ability to recognize and target and kill the very beta cells that are critical for insulin production. And, as Dr. Leiter pointed out, the animal models that have been developed and exploited at The Jackson Laboratory has made our work very easy in trying to understand better the basic processes of this disease. And perhaps the most dramatic observations that we have made in the last 10 years is that the T cells, the cells that are most prominently involved in the destruction of the islet cell of the pancreas, are very much regulatable. We have learned that the T cell works like a lock-and-key mechanism, where each T cell recognizes a protein uniquely, and the T cells that recognize the insulin-producing beta cells are not the same as the T cells that recognize a virus or a bacteria. We have also learned that the process of T reactivity is a multi-step process, in which not only is there recognition of the tissue but then subsequent exposure to other signals that determine whether the T cell gets turned on or turned off. These fundamental observations have changed the way we have thought about how we are going to manipulate or alter the T cells responsible for generating immune responses against autoimmune diseases in self tissue. What we have learned is that our basic processes of immune intervention that we have used over the past 2 decades, which have had extraordinary success in treating autoimmune disease to some extent, but more often kidney transplants and liver transplants, that these are sledgehammers. These are drugs that suppress the whole immune response. They have worked very well, but they lead to many complications and toxicities. They require treatment for the whole life of the individual who has the transplant or the disease, and although they have been very successful, they beg for more sophisticated and targeted approaches. And what we have learned is that we can now develop drugs against these lock-and-key mechanisms on the T cells, the drugs against the receptor itself that recognizes the islet cell, as well as drugs against these other molecules that are necessary for signaling a competent immune response. I think there is a tremendous amount of excitement and enthusiasm in the community that some of these drugs, when combined in appropriate ways, will lead to what we call immune tolerance, the ability to treat with drugs for a short period of time and reeducate or train the immune system so it does not recognize any more its self tissues, like in the pancreas, and that we can subsequently do islet transplantation in a setting in which the islet cells will not be rejected. It is these exciting new approaches to the treatment of immune disorders that actually led the NIH and the JDF and, as you mentioned earlier on, a very concerted effort among different institutes to put together what I think is an exciting, bold new initiative. It is called the Immune Tolerance Network. It is a 7-year project funded, as I said, by the NIH and the JDF--I have been fortunate to be asked to lead this effort--in which over 70 investigators from around the world will be putting their energies towards trying to study not just diabetes, a very important area in islet transplantation, but other autoimmune diseases like lupus and multiple sclerosis and rheumatoid arthritis, to work with kidney transplantation as well, and even allergy and asthma, to try and understand common mechanisms in regulating all of these diseases and common approaches, as I say, redefine and reeducate the immune system, such that we can now avoid the attack of these terrible T cells. This effort, which has just begun--yesterday I closed a meeting of the 70 investigators, our first--is supported by $140 million from the NIH and the JDF over the next 7 years. It is a tremendous opportunity. I feel a tremendous amount of pressure, in fact, to make a difference in this thing. It is a testament to the confidence of you in the Senate, to the research community, that we really are now putting these kinds of dollars in, and I truly believe that we need to continue to do that, and we need to do that because the basic research underpinnings that have gotten us here today don't just stop, that we need to keep moving on, to come up with new ideas and new opportunities. Genetic research is going to have tremendous impact, as well. So there is no doubt that the recent scientific developments represent remarkable progress in our understanding of human disease. We have new tools now, those little chips that Dr. Kahn brought today--which may now give us a fresh approach to the treatment of diabetes and related diseases. I urge the Congress and the NIH to implement the recommendations of the Diabetes Research Working Group. I sit before you today full of enthusiasm and optimism. I am confident that 50 years from now, when we look back at the turn of the century, it will not be remembered as a time when we argued over managed care and how to redefine our public health system. It will be regarded as a golden age of biology that marked the beginning of the end for so many diseases. And like the industrial revolution at the end of the last century, the biological revolution will be remembered as a time of innovation and discovery, when diseases like diabetes are only a memory. Thank you. Senator Collins. Thank you very much, doctor. Dr. Leiter, first I want to again commend you and the other two scientists here today for your excellent work and commitment in this area. I was struck by your testimony that if the two inventors of insulin, Dr. Banting and Dr. Best, I believe the names were, were to apply today for an NIH grant to support their theory, that you do not believe they would be funded based on what they would be going to NIH with. That suggests to me the magnitude of the problem, and that there are many meritorious projects out there that we are just not funding, and that we may be missing the chance for a tremendous breakthrough. Is that what you are trying to tell us by using that example? That is a startling statement. Mr. Leiter. Things have improved dramatically over the last 2 years, as your diagram and the testimony of Dr. Gorden have indicated, so with the funding of one in three applications now, that really is a very positive step. But still, within the one out of three that gets funded, there is probably one out of three in there that is deemed excellent but not outstanding. The peer review panel, just to ensure that NIH is going to get what it hopes to get, which is a real positive outcome, will send the investigator back a message, ``Get us some more preliminary data and come back, and let's then reevaluate your hypothesis to see how close to the scientific truth it really is.'' And if we can just get that second out of three grants funded, progress will be moved forward because the scientist will not be frustrated, will not be scraping. Thank goodness for the Juvenile Diabetes Foundation and the American Diabetes Foundation. If you are from Maine or Michigan or some other cold weather State, jump starting in winter time is a very common concept. Well, these two private organizations have jump started scientific research in diabetes in this country, and it is through their efforts that many of these one out of three grants are not lying fallow but actually some of that preliminary data is being obtained. I know Director Varmus is aware of the problem, I know NIDDK is trying to remedy the problem, how to fund innovation at the same time as NIH is putting its money on sure things. So it is certainly a problem that is being tackled at the governmental levels. They are aware of it, they are trying to deal with it, but certainly it will be helped out if the Diabetes Research Working Group recommendations, at the funding level you and your co-sponsors have supported in the Senate, were to become reality. Senator Collins. I appreciate your mentioning the terrific support provided by the Juvenile Diabetes Foundation and the American Diabetes Association. I am so impressed with their advocacy and their commitment to research, and I know that Dr. Bluestone, also the project that you described involved some funding, some private funding, as well. I guess that leads me to a question for Dr. Bluestone, which is, how well does it work to have private funding in addition to NIH funding? Are there problems with merging the funding streams, or are you able to handle the combination of private and public dollars without any problems? Mr. Bluestone. I can speak about the JDF Foundation, which I have had the most experience with, which may actually be a pioneer in this area, I believe. What they have done is, they have actually partnered very effectively with the NIH. They have taken advantage of tremendous talent in the NIH and the review process identifying outstanding research opportunities, and helped to support research. One of our grants is basically an NIH-funded grant that at the time in the early 1990's had to be cut because of administrative cuts due to budget restrictions. The JDF came in and restored that cut so we could do all the research that we had hoped to do. So it has been an exceptional partnership, I believe. More recently, the ability of the JDF to actually help in getting the tolerance network going, contributing 10 percent of the money actually that is going towards this network, was actually an extraordinary opportunity. Again, they did it in an incredibly productive way, by not trying to fund separately or fund independently, solely, but here to partner with the NIH and put the money together. So if the JDF could be used as a role model in this, it would be very good for all of us. Senator Collins. Thank you. Dr. Kahn, I want to get back to one of the key issues that has been before us, and again I want to salute you for excellent work. You made a very important point, which is, the budget numbers recommended by the Working Group are not plucked out of a hat. They are not arbitrary. They are tied to a planning process and to achieving specific goals, and that to me is the strength of your report. What has been NIH's reaction to your good work, to the funding levels? Are you satisfied with the reaction? And I realize I may be putting you in a little bit of a difficult spot. Maybe, though I am very pleased that Dr. Gorden has stayed for the hearing, I should have him go away for this part. Dr. Kahn. No, that is fine. But yes, I think that as you gathered from Dr. Gorden's testimony, they are caught in a bind in a sense that they have many initiatives brought to them and a limited budget. I think that NIDDK actually should be commended for, as Dr. Gorden pointed out, jump starting a number of things in this report. NIAID, the National Institute on Allergy and Infectious Disease, in this program that is partly through that institute and partly through NIDDK, and the JDF has also jump started some of the initiatives related to the autoimmunity. So there has been actually some very positive response by a number of institutes and institute directors, and attempts to use some of the existing funding to pick, if you will cherry pick some of the ideas from this report to see if they could not be jump started. Clearly, however, with the existing levels of funding that are available, the type of effort that we hoped could be achieved cannot be achieved. It will take a significant increase in diabetes research funding to achieve this, in part because these efforts really require a multidisciplinary, multifaceted approach. You heard from Dr. Bluestone that this immunology initiative alone is going to be $140 million over 7 years, and we believe that our genetics initiative could be in the range of $100 million over 7 or 8 years, or maybe even more. So each of these initiatives, if we really want to concentrate and maximize the scientific opportunity, will take a very significant investment. Of course, we can do something with half that amount or a third that amount, but it will be half as much or a third as much. You cannot get the whole process for part of the price. So I think that NIH has made some efforts to actually use its resources to do this, but I think that they will be greatly enabled by, hopefully by the legislation or the recommendations that you have made and that have been passed by the Senate. And I think that that would allow the full magnitude of the report to really have its maximal impact. Senator Collins. I think that is a very important point, because given the state of the research, we really do need this infusion of funds and we need it now, if we are going to achieve the goals. And that is one reason I want to hold this hearing today, to try to give momentum and try to frankly put some pressure on NIH to keep pushing forward in this area, since I think it is very clear there is very strong congressional support for doing so. Dr. Bluestone, you gave a very lucid explanation of how the type 1 diabetes autoimmune--of the fact that it is an autoimmune disease. As I have read more about type 1 diabetes, it seems to me that islet cell transplantation has tremendous promise, but I do not understand how we are going to prevent the body from attacking the transplanted cells. Or at one point I thought, ``Why don't we just transplant pancreases? Why don't we?'' I mean, maybe that is an option, but it seems to me you always have the problem of turning off whatever is causing the host body to attack the islet cells all over again. Is that part of your work? It sounds like that is part of the focus, is to figure out how, without using the kinds of powerful anti- immune system drugs that cause so many other problems, we can tackle that issue. Mr. Bluestone. Yes. It is actually worse than that. The transplant has two problems. The first problem is what you said, which is, the autoimmune response which was ongoing in the patient before you put in the islets is still ongoing. The second problem is, you have now taken islet cells from another individual, like when you take a kidney, and you have that so- called allo response, the foreign response, as well. So there are two responses you have to deal with. In kidney transplantation we only have to deal with one; in liver transplantation, only one. So you are right, it is a tremendous challenge, but the things that I was talking about, the ability to understand the basic mechanism by which the T cell recognizes both the autoimmune and the alloimmune response, is exactly what we are targeting right now. And what is very exciting is the fact that the transplant gives you is an opportunity to intervene just at the point when the T cell is just about to recognize the tissue. In an autoimmune patient, there is now data that at 6 months of age there are already signs in the type 1 diabetic of an immune response against the pancreas, and it is progressive, so that by 6, 7, 8, and 10 years old it is to late, the patient is diabetic. With the transplant, we know when the transplant is going in, and we can now try to manipulate the immune response precisely at that time, which I think will give us a tremendous advantage. Finally, the only other point that I would make is that we do do pancreas transplants right now, and in fact they are rather successful. But one of the great opportunities in islet transplantation is the opportunity to be able to not only manipulate the islet cells so that when they go in they are less likely to be rejected, which is difficult in pancreas to do, but also the cost and morbidity associated with surgery and clinical care will be avoided. And then, finally, of course, are great opportunities led by places like the Joslin to try to create the ability to grow these cells, so that even though there are only about 4,000 pancreases a year, that we might be able to treat the millions of people who are going to be able to take advantage of the technology. Senator Collins. And, as you pointed out in your testimony, the work you are doing also has implications for other autoimmune diseases like multiple sclerosis, I think you said. Mr. Bluestone. Yes. It is actually true that there is great opportunities. When I talk about this in public, I talk about Teflon and the space program. I truly believe that the outcomes of these kinds of research are often serendipity and unanticipated, and there is, from cancer to AIDS to the various autoimmune diseases, these are processes that are dealt with by the immune system over and over and over again. And what we have learned is that immune disorders really affect many diseases and dozens of diseases now, so I am optimistic that the basic research done in the area of diabetes will almost certainly have implications for many of these other diseases. Senator Collins. Dr. Leiter, you mentioned in your testimony that you are working with the NOD mouse to try to identify predictors, I believe, so that we could identify young people who are at risk for type 1 diabetes. Could you explain more about that research? That very much interests me, because perhaps if we can intervene at an earlier age, we can prevent some of the devastating consequences of diabetes, or figure out eventually how to switch off the cell that is causing the problem. Mr. Leiter. The basic approach that we have to predicting what the genetic makeup is for a program to get diabetes is marriage. We heard Dr. Kahn has just had a daughter married, and let us see, Mr. Jump I think just had his daughter married. Well, we choose different husbands and wives for NOD. The NOD mouse is really a replicate of just one single human being at risk to get insulin-dependent diabetes. So depending who we call in as a marriage partner, we come up with different genetic combinations that will lead us toward diabetes or away from diabetes. And sometimes, to our amazement, if we choose a certain marriage partner, the kind of diabetes that ensues may not be the same kind of autoimmune diabetes that the NOD has. So we see all kinds of complex intermixtures, telling us once again that genetically there are all kinds of ways to get diabetes. But with regard to pre-diagnosis, there is one major factor that tells us that the mouse really could get diabetes if the genetic program would allow it, and those are genes which tell the teachers of the T cells that Dr. Bluestone was talking about. There is a certain genetic component that tells these teachers of the T cells how to teach. And in humans at high risk for insulin-dependent diabetes, we can see that there are certain similarities between their instructional genes or T cell education and what the NOD mouse has. So genetically that is the first thing we look for, for an autoimmune genetic bad education, and that is true in humans as well. So there is a major genetic component in the mouse and in humans for type 1, and they are in the same place genetically. But after that, you really are limited to some of the immunologists' and the clinicians' tools, and that is, you look in the blood. You could either do what Dr. Bluestone might do, and pull out some T cells and show them something that the beta cell makes and ask, ``Do you recognize this, and if so, would you attack it or will you let it go?'' And if that recognition is there without letting it go, then you already know that mouse is on the road to developing type 1 diabetes and you darn well better think about doing something early if you want to stop that, and that is what Dr. Bluestone and his 70 other scientists are working on doing. The other thing you can do is measure antibodies. If the beta cell is being attacked by the T cells, then signs of the destruction are antibodies against beta cell components like insulin and other components. So if you see this combination of a major genetic component that leads to a bad education of the T cells, so they do not tolerate the way they should, so teaching tolerance is missing; if you see that the Beta cells are being attacked, as reflected by these immune signposts, and you could also do a glucose tolerance test, those would be signs in a mouse or a human that it is time for some sort of intervention. And that, of course, is what NIH is working with the JDFI and the ADA to develop, just the right kinds of interventions. Senator Collins. Thank you. I am fast reaching the end of my scientific knowledge. Once I get past the T cells and the beta cells and the islets, I am really on thin ice, but fortunately we can rely on the experts. Dr. Kahn, I had one other area that I wanted to raise with you. I think we heard from our panel of people coping with diabetes a very important point. Ryan mentioned it. In fact, all of them mentioned it, one way or the other. And that is that there is a common misperception about how serious diabetes is, and that the public does not understand how serious the disease is and how devastating the consequences can be. Ryan points out that if you take a classroom of students, you cannot tell who has diabetes and who does not by looking at them. Mr. Fuller talked about when he first learned his father had diabetes, he knew it had something to do with insulin and that was about it. Mr. Jump talked about that he was in denial at first about his own diabetes. Ms. Fernandes did not realize the risks of going blind at first. I think that part of the challenge that we face is the lack of public awareness about the severity of diabetes. Do you think that that lack of public understanding has contributed to the fact that diabetes research has been so severely underfunded? Dr. Kahn. That is a very tough question. I definitely would start off by agreeing with your perception, and by the perception that has been stated, that too many people believe that diabetes is not a serious disease, and it obviously is a very serious disease. I would actually say that the problem in a certain way is greater in the area of type 2 diabetes than type 1 diabetes. In type 1 diabetes, we are more sensitive to the fact that these are young children, that their life styles and their growing up period of their life is very disrupted with management of this disease. Their parents are obviously distraught, and they have to help manage this disease. And of course we talk about a lifetime of disease. We are perhaps a little less sympathetic to the older person who has diabetes, but who is equally devastated, and who may have in fact many more complications because of their age. They may already have heart disease or have kidney disease or have other chronic, debilitating diseases that only make the situation for them that much more complex. And Mr. Jump gave us some idea of even for an individual like himself, how many different medications and how many different monitorings he has to do. And both of these, even type 2 more than type 1, seem to be so silent. The type 2 diabetic individual, we have heard that as many as a third to a half of them don't even know they have the disease. And yet they are, during this period of silence, actually at risk for developing complications. Many times they present first with some of the complications, the neuropathy, the retinopathy, and so forth. I don't know if public awareness is the rate-limiting step in our research funding, because I think that obviously the ADA and the JDF have both done a lot to increase public awareness about this disease. But I think that it is perhaps one factor that has given somewhat less pressure or tension on this disease than on AIDS or cancer, which are such rapid devastating diseases. Here we have a slow and devastating disease. And I think that we need to be aware that because it is slow and because it looks like not much is going on, does not mean that not a lot is going on. And so I think that we do have to be cognizant of the fact that more people die of diabetes each year, by a factor of several fold, than die of AIDS, and more people will have diabetes complications of various sorts than many other diseases which are much more high profile. So I think that there is a need to realize how important this is. The economic impact I think also speaks to this. It tells you that there is a very big public health burden as well as a personal health burden. So I think that there are plenty of reasons that we should be more attentive to this disease. I think that Congress' initiatives, both on the House and the Senate side, have been tremendously helpful. And I hope that with this and with more funding for NIH, that institute directors like Dr. Gorden will have more resources to put into this disease, because I know that they would like to. He cannot say that but we can say that. He would like to do it, we would like him to do it, and I think that what he needs is a green light from you to go ahead. Senator Collins. And that he has. I want to thank you very much for your testimony today. I am trying to do my part to promote awareness of diabetes, not only through this hearing, but also today the Senate Diabetes Caucus which I chair is holding a free screening for Senate employees and for Senators. It is going to be held in the nurse's station on the first floor between the Hart and Dirksen Senate Buildings, and I encourage anyone to take advantage of the free screening today. I am going to do it myself, although having learned a lot about diabetes, I must say I am a little bit nervous about what the results may be. In all seriousness, I do want to thank all of our witnesses today. Again, I want to thank you for your dedication to diabetes research, for the excellent work that you are doing in your labs, for the exciting research that you have underway. I hope that I will be able to hold another hearing 5 years from now, if the voters of the State of Maine have the judgment to send me back for a second term, and that I will be able to hear of the exciting breakthroughs that you have accomplished because we have given you the resources that you need to achieve the goals set out in the Working Group's report. So I want to thank you very much for sharing your experience with us today. I want to thank all of our witnesses today for coming forward and sharing their unique perspectives. I particularly want to thank the people with diabetes who testified today. I think that it is so important that we do put the human face on this very serious disease, and without their very eloquent and moving testimony, this hearing would have been far different. So I want to thank particularly our second panel for coming forward today. I want to thank Dr. Gorden as well, and to assure him that he has the very strong support of Congress, he has that green light that Dr. Kahn referred to. I am very committed to continuing the fight against diabetes. We have learned a great deal today, and I think we have learned there is reason for great hope and optimism, that indeed the research is at a stage where we can see breakthroughs happening. It is very exciting what is going on, and I think that as long as NIH works with Congress to fully fund the recommendations of the Diabetes Research Working Group, that we will make the kinds of breakthrough that are going to allow us eventually to prevent and cure diabetes, as well as giving improved treatments and improved quality of life for those who are suffering from the disease right now. I also want to thank my staff, which has worked very hard on this hearing. Priscilla Hanley, of my personal staff, has worked very closely with me on all the initiatives I have undertaken for diabetes, as well as the members of the Subcommittee staff, particularly Lee Blalack, Elizabeth Hays, Mary Robertson, and Justin Tatram. I also want to thank again the American Diabetes Association and the Juvenile Diabetes Foundation for the expertise that they have provided me. I am going to continue the fight, as well, and I thank you very much for your contributions. The Subcommittee is now adjourned. 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