ST. JOHN • Dietitian Michelle Preston leads a group of customers with diabetes through the aisles of a busy Shop 'n Save on St. Charles Rock Road on a recent frigid night.

Preston pulls out two test tubes and turns them upside down.

"Watch what happens to your blood flow when it's full of A1c," a hemoglobin that's a marker for average blood glucose levels, she says. In one tube, particles barely move through the thick, syrupy solution.

Ethel Endsworth's eyes widen. Endsworth, 62, of St. John, was diagnosed with diabetes 12 years ago but only recently lost weight and dropped her hemoglobin level. "That's what your blood was like," Preston tells her.

Over half of adults in the United States will have diabetes or prediabetes by 2020 at an annual cost of $500 billion — or 10 percent of total health care spending, according to new analysis by UnitedHealth Group. About 37 percent of Americans now have diabetes or its precursor.

The country is on track to become the "United States of Diabetes," the report warns, with more people suffering from implications such as heart disease, kidney damage, nerve damage and blindness.

The trend is not inevitable, however. And education programs such as this free dietitian-led tour at a grocery are key, experts say. Efforts to prevent and control the disease are coming to barber shops, coffee shops, drug stores, health clubs and churches.

"When you have diabetes or prediabetes, your health care is everywhere," said Dr. Deneen Vojta, who led the creation of UnitedHealthcare's diabetes prevention and control programs involving the YMCA and Walgreens. "It is the small lifestyle decisions you make everyday, and that happens where we live, not just in the doctor's office."

'WE CAN HELP YOU'

Before Preston's group learned about portion size, nutrition labels and how to use a tennis ball to estimate how many carbohydrates are in an apple, Shop 'n Save pharmacist David Komor talked to the group about testing their blood sugar levels and blood pressure. He asked about their LDL, HDL and triglyceride levels.

"I know we're just a grocery store chain ... but we want to be and are a part of your health care team," Komor told them. "We certainly are accessible, and we can help you."

Doctors can't be the only line of defense against diabetes because of the disease's unique challenges. Type 2 diabetes, which makes up 95 percent of diabetes cases, progresses over time without obvious symptoms. It is largely preventable through diet, weight management and exercise.

Federal figures estimate that 24 percent of the 27 million adults with diabetes are undiagnosed, and 85 percent of the 67 million with prediabetes are unaware of their condition.

"Unlike HIV or breast cancer, where it's an acute illness and people are scared into dire consequences of not acting, diabetes and prediabetes are bit more subtle," Vojta said, "People tend to say, 'Well that's not me. That's her over there.' "

'ANYTHING ... SEEMED WORSE'

Endsworth said she didn't break her bad habits until 10 years after her diagnosis, when her medication stopped working. She increased the dosage, but was no longer able to control her blood sugar. "My weight was up and down all the time. My joints hurt. Anything that was wrong seemed worse," she said.

She slowly began to change her diet and exercise and was eager to find support in her pharmacist and grocery store. "I'm always looking for improvement, and this makes it really nice," Endsworth said after learning about the healthiest types of butter and cuts of meat. "It makes it really convenient, and it was free."

Eric Armbrecht, executive director of the St. Louis Diabetes Coalition and assistant professor of medicine at St. Louis University, said resources must be available when people are ready to change, which is often not in the doctor's office.

The coalition is taking part in a year-long study looking at the effectiveness of holding group and individual education sessions about managing diabetes at coffee shops, cafes, churches — wherever a person would like to meet.

The interest in participating in the sessions, which started this month, has been overwhelming, Armbrecht said.

"People need encouragement, and where do you go for encouragement and support for things going on your life?" he said. "It's not your doctor's office or your hospital."

THE BARBER KNOWS

Some health departments in Florida and Pennsylvania have shown success with offering diabetes education along with a haircut. Barbers talked to their customers about risk factors and complications, leading many to get tested.

Shop 'n Save has offered two-hour store tours and discussions with dietitians and pharmacists at St. Louis area stores for the past three years.

Many Schnucks and Shop 'n Save stores have specially trained pharmacists that can meet one-on-one to review diabetes patients' often numerous medications and help with blood glucose and blood pressure screenings.

"One of the things I love about grocery stores is we're in such a unique position to help people," said Kim Kirchherr, a registered dietitian for Shop 'n Save, because two cornerstones of managing diabetes is proper diet and adhering to medications.

In turn, she said, stores hope the free services will foster customer loyalty.

UnitedHealth Group, one of the nation's largest insurers, launched its new community partnership with the YMCA and Walgreens this spring in six metropolitan areas. It will be coming to the St. Louis area next fall and by the end of 2012, will be offered in about 40 other areas.

Trained "lifestyle coaches" at YMCAs will take groups of people with prediabetes through 16 training sessions followed by monthly maintenance meetings. The coaches will be reimbursed based on member participation and weight loss.

Pharmacists at Walgreens will help those with diabetes adhere to their doctors' plans, identify gaps in therapy, and reach their goals for controlling blood glucose, blood pressure and cholesterol.

Another insurer, CIGNA, launched in February a 12-week worksite program aimed to combat metabolic syndrome, which increases the risk of developing diabetes.

"It's a different condition, and we realize we have to meet people where they are," said Vojta with UnitedHealth.

Studies and pilot projects shows that such programs work. Even small improvements can have a big impact.

Moderate exercise and a 5 percent weight loss can reduce the incidence of diabetes by 58 percent among those at risk of developing the disease, according to a 2002 federally funded study of more than 3,000 people with prediabetes.

Komor, the pharmacist at Shop 'n Save, told the group gathered in the corner of store that they are just as likely to have a heart attack or stroke as someone who has already had a heart attack.

"You really need to understand how to take your medication and why it's important to get a grip on your disease," Komor said, "or it will get a grip on you."