Next month, IEEE PULSE will take an in depth look at the worldwide diabetes epidemic. We’ll be exploring societal and demographic trends around the world, as well as new initiatives involving telemedicine and mobile apps that help manage the disease along with advances in high-tech treatments, such continuous glucose monitoring. To begin the conversation, Dawn DeWitt, a physician and Professor of Medicine at the University of British Columbia in Vancouver, Canada, argues here that more than expensive medical solutions, a greater political will and public commitment are needed to combat the diabetes epidemic in the United States.
As a doctor with an academic, clinical, and personal interest in diabetes, I worry that we’re in for a real struggle—and our success is part of the problem. As kids, many of us were outside running around for hours, only coming home for dinner, which rarely, if ever, consisted of junk food or fast food. Decades later, in a land of growing wealth, millions of fast food restaurants, and a greater comfort and ease marked by a sedentary lifestyle and expanding waistlines, a rapidly growing number of people—both young and old—grapple with type 2 diabetes.
The International Diabetes Foundation interactive maps show facts and figures that alarm doctors and insurance companies. Twenty-four million people in the United States currently have diabetes. That’s about three times the population of New York City, the entire population of the states of New York and Massachusetts combined, or more than the entire population of Australia. Type 2 diabetes is a classist and racist disease, disproportionately affecting African Americans, Hispanics, immigrant populations, as well as Native Americans. Even more concerning, approximately 200,000 people die in the U.S. every year from issues related to diabetes. Finally, more than 200,000 youth under age 20 have diabetes and the majority of these cases are related to obesity rather than to autoimmune, type 1 diabetes, which accounts for only about 10% of all cases.
Why is there such a growing problem? To begin, gone are the days of lumberjacks and farmers working the land, using muscle instead of machines while expending thousands of calories each day through manual labor. And yet, we haven’t let go of large breakfasts and even larger evening meals. As a small example, housewives in the 1960s apparently expended 111 more calories per day doing housework, enough of a difference so that modern women using labor-saving devices will, on this basis alone, increase weight by 20 pounds over 10 years, and thus increase their risk of diabetes by more than 60% (1, 2). Americans are no longer, for the most part, in jobs with significant physical activity but we still value big meals, and it doesn’t seem that public awareness (take, for example, the movie Super Size Me—which is really a much-needed lesson about fast food, carbohydrate, and fat intake more than it is a message about McDonald’s) is going to reduce excessively large meals compared to caloric needs in restaurants anytime soon. Rural Americans are worse off than urbanites, simply because the availability of cars and parking means even less walking in the course of a day.
What then should Americans do? According to the American Diabetes Association, $245 billion was spent in 2012 on health care resulting from the twin epidemics of obesity and type 2 diabetes. Compare that to $801 billion spent for 16 years of schooling for U.S. students (via Edudemic). Since diabetes education is a key part of diabetes control for patients, even a modest shift in spending for education in schools toward prevention, including luxuries such as more physical education, could make a huge difference. We can also educate children and their parents about substituting skim milk for whole milk once children’s nervous systems are well-developed and no longer require fat, certainly by the age that they start school. We can substitute no or low-calorie drinks for juices and sugared sports drinks. Or, we could take a lesson from Finland, which reduced its heart attack rate—once the highest in the world—by 75% using a range of public health measures starting in the 1970s. These included cooperating with the food industry to change food ingredients such as salt and cholesterol, and encouraging people to drink skimmed milk instead of whole milk (3). The results were as dramatic as putting everyone on medications for cholesterol and blood pressure.
There is also a nationwide meal-based math problem involved: one Big Mac meal is 1000 calories, so that “treat” means 20 miles of walking to burn it off. If 40% of Americans eat fast food once per week and 20% go twice a week, we’ve got a lot of walking to do. We need to change the American attitude that fast food is “normal” or even a “treat.” Unfortunately, even pediatricians disagree about eliminating fast food, pointing out that many families cannot afford healthy foods, and research backs up the claim that less wealthy neighborhoods have less access to healthy foods needed to combat obesity and diabetes.
A legislative approach, e.g. taxing fast food and subsidizing fresh fruits and vegetables, is unlikely to work in the U.S. because of powerful fast food lobbying. Similarly, standardizing food portions or other public health attempts such as those undertaken by Finland would be seen as un-American if they diminished freedom of choice regarding unhealthy foods. Dying slowly from obesity and diabetes, it seems, does not spur the imagination or galvanize action in the same way as other world crises, even those depicted only in film. Perhaps the youth of today along with social media and Hollywood could tackle the problem more effectively?
While important organizations such as the Centers for Disease Control and the Harvard School of Public Health have programs and grants, the call for action has not reached a critical point in the public’s mind. Imagine what you could do in your area to change calorie intake or expenditure even by 100 calories per day: eliminate two crackers or 8 oz. of juice, or add about 2 miles of walking a day for a 100-lb. person, achievable with 30 minutes of exercise per day in schools.
Advances in the Treatment of Diabetes
In the meantime, huge strides have been made in diabetes diagnosis and treatment. Our ability to diagnose diabetes earlier has improved dramatically since about 1990, with simple and relatively inexpensive tools such as glucometers and standardized hemoglobin A1c (A1C) measurements now widely available.
The range of available oral medications has increased through scientific discoveries about how glucose is used in the body. A complex range of mechanisms regulate our blood sugar levels, storing blood sugar in the liver after we eat, releasing it slowly later (so we don’t have to eat 24-7), and moving it inside cells as they need energy. As scientists understand those mechanisms, new drugs are designed to that cellular level. These medications do everything from increasing secretion of insulin from the pancreas (sulfonylureas), to blocking the release of the hormone, called glucagon, that promotes release of glucose from the liver (incretins), to decreasing the manufacture of incretins (DPP-4 inhibitors) to efficiently moving glucose into muscle cells (TZDs). Several classes of these agents do not cause much-feared hypoglycemia. The most commonly used agent, metformin, which makes cells more sensitive to insulin, does not cause weight gain, and studies suggest that it may also offer some protection against cancer. A game-changing transition from mostly human insulins to more predictable insulin analogues has occurred over the last 2 decades, allowing patients more freedom to match their insulin to their lifestyle rather than demanding strict and regular meal-times and snacks as required by older insulin treatment regimens (4).
For patients with type 1 diabetes, innovations including insulin pumps, continuous glucose monitoring systems (CGMS), and various computer algorithms, not to mention closed-loop pumps with glucose sensors and treatment algorithms, have revolutionized glucose control. Studies show that patients who have access to continuous glucose data can improve their glucose levels and stability dramatically over only a few weeks while reducing their risk of hypoglycemia significantly. And, while early promising, Canadian work with islet-cell transplants has not been as successful as hoped, new immunomodulatory agents hold promise, though none are ready for widespread use.
Hope on the horizon?
Finally, in the last decade, we are beginning to amass long term data on the success of glucose control (a reduction of 1% A1C or 18 mg/dL in glucose decreases complications by about 50%) and even a short period of good control has a lasting effect on reducing complications. We now have cholesterol-lowering medications that lower the risk of heart attacks by 25-30% and blood pressure medications that help prevent long-term complications of diabetes including heart attacks and kidney failure. The blood pressure medication class known as ACE-inhibitors reduces the risk of kidney failure by about 30%.
As a generation of people with diabetes have had access to these medications, grim statistics about kidney failure are changing for the better. Unfortunately, only about 60% of patients take their diabetes medications regularly, even those who require insulin to stay well, with cost being a major barrier. As the Affordable Care Act goes into effect, and “Medical Homes” provide comprehensive care at a local level, we can only hope that policy-makers and the public might consider and push for interventions such as those supported by cost calculations published in 2012 by Howard Wild, of MedImpact Healthcare Systems, who estimated that for every $1 of “free” medications, the system would save $1.04 in costs. Multiply that by billions and we’re starting to make a difference.
Unfortunately, while there are no easy answers, prevention, education, and whatever it takes to change the “American lifestyle” are clearly the keys to success. We know what works; Li et al. published the most cost-saving interventions in 2010 in Diabetes Care (6). What we need is the political will and a public commitment to supporting health rather than an expensive medical system at the other end. In the meantime, this author is enjoying a coffee (8% decreased risk of T2DM) without sugar (23% increased risk in T2DM) and wishing success to the personal efforts of readers who are tackling this problem. Gotta run (literally) and so should you—remember that 2 miles? Find a friend, walk while discussing this article, and prevent diabetes.
REFERENCES
- Wannamethee SG, Shaper AG. Weight change and duration of overweight and obesity in the incidence of type 2 diabetes. Diabetes care. 1999;22(8):1266-72. Epub 1999/09/10.
- Lanningham-Foster L, Nysse LJ, Levine JA. Labor saved, calories lost: the energetic impact of domestic labor-saving devices. Obesity research. 2003;11(10):1178-81. Epub 2003/10/22.
- Puska P. From Framingham to North Karelia: from descriptive epidemiology to public health action. Progress in cardiovascular diseases. 2010;53(1):15-20. Epub 2010/07/14.
- DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA : the journal of the American Medical Association. 2003;289(17):2254-64. Epub 2003/05/08.
- Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes care. 2010;33(8):1872-94. Epub 2010/07/30.