Diabetes is big business, and many have been convinced that managing it forever is their only option. But it is possible to cure the disease.
Chuck Lynch figured that after being diagnosed with type 2 (adult onset) diabetes, he was destined for a life of daily finger sticks and medication to keep the glucose level in his blood at a normal level.
Everything he'd heard about type 2 suggested strongly that his only choice was to make the best of it. "I thought it was something you managed for the rest of your life," said the 62-year-old Lyme, Connecticut, resident. "I didn't know you could cure it."
Experts hesitate to talk about "curing" diabetes, given the medical complications it can cause that will require lifelong monitoring. But the American Diabetes Association says that maintaining normal blood sugar without medication for at least a year could be considered a "complete remission."
It's not a message you hear very often if your information about type 2 diabetes comes mainly from TV commercials for the devices and medications used to manage the disease. Diabetes is a big business, worth tens of billions of dollars to the health care system and the pharmaceutical companies that hold the patents on those devices and medications.
Another reason you don't hear about remission is it takes a great deal of effort. Even the health care system seems content to prescribe complex lifelong treatment regimens instead of equipping people with the tools they need to effectively manage type 2 diabetes, possibly reverse the disease or, best of all, avoid it completely.
Chuck Lynch created his own diabetes-reversal program, and it has become the retiree's new job. He dropped 30 pounds with the help of Weight Watchers, and now carefully measures every morsel and drop that goes into his mouth. He joined a gym where he does yoga, water aerobics, and other exercise classes several times a week.
"I went to town on it," he said. And it has paid off. "I feel better than I have in years. I want to keep it that way."
FRAMING THE PROBLEM
Slender joggers, hardly typical people with type 2 diabetes, laud their glucose-reading meters and test strips to evening network TV news viewers, typically middle-age and older, prime type 2 targets. Friendly older gentlemen speak of their "diabeetus" medication in other commercials as if the deadly disease is a pal who stopped by to shoot the breeze.
Don't be fooled: Diabetes kills. And maims. This year alone it will kill 3.2 million people worldwide. It's the seventh leading cause of death in the United States. As many as 80 percent of people with diabetes will die from heart attack or stroke. Half will likely experience damage to the nerves in their limbs. Diabetic foot disease, caused by changes in blood vessels and nerves, often leads to ulceration and eventual amputation. In fact, diabetes is the leading cause of non-traumatic lower-limb amputation. Ditto for kidney failure. One of every 50 people with diabetes will become blind within 15 years.
The World Health Organization (WHO) calls diabetes a "slow-motion catastrophe." From an estimated 30 million living with it in 1985, to 171 million in 2000, a minimum of 366 million people will have been diagnosed with diabetes by 2030.
Meredith E. Young, an assistant medical professor at Montreal's McGill University, researches the role of language in shaping how the media present, and the public perceives, medical conditions. She said in an email that "media attention to particular disorders seems to influence public perceptions of what is serious, rather than what is seriously driving public attention (and therefore media attention)."
When the media do focus on type 2 diabetes, said Sarah Gollust, assistant professor at the University of Minnesota School of Public Health, they give twice as much coverage to the behavioral risks for it than any of the other factors that contribute. But this over-emphasis on personal responsibility tends to blame and stigmatize people with type 2 diabetes or who are obese. Those living with the disease may feel it's their fault if they can't always maintain the ideal blood sugar level. Worst of all, said Gollust, public support could erode as people are expected to cover the costs, however they can, of a medical condition it's believed they brought on themselves.
Public support for addressing diabetes is imperative when you consider the tremendous amount of money it costs to manage the disease. One of every five health care dollars spent in the U.S. is for someone with the disease. Medicare, the federal insurance program for seniors, pays 60 percent of the nation's annual $83 billion diabetes-related hospital bill; Medicaid, the federal-state insurance program for low-income citizens, pays another 10 percent.
"Right now we're having a diabetes epidemic," said American Diabetes Association president for health and education Geralyn Spollett, an associate nursing professor at Yale University's Diabetes Center. "People don't realize the urgency of the problem we have with people at high risk." Spollett said the challenge is to realistically frame diabetes so it's not scary to the point of making people feel powerless. On the other hand, she added, "If you give a message that everything is fine, the seriousness of the disease doesn't come through."
THE THIN LINE
Susan Dentzer, editor-in-chief of Health Affairs, calls in the journal's diabetes-focused January 2012 edition for "an all-out assault on the condition -- and, since obesity and diabetes walk hand-in-hand, a long-term commitment to radically reshaping the obesogenic environment we live in."
The fat-creating environment makes it exceedingly difficult for people at risk for diabetes -- because of poor diet, obesity, and lack of exercise -- to resist the forces that work against their own good health. The environment typically features structural factors such as impractical transit systems, and towns and cities dependent on the car; desk jobs and non-physical recreation such as TV watching, video-gaming, and web-surfing; and a savvy food industry that has hooked the public on a great deal of unhealthy food items.
Most perniciously of all, the diabetes-inducing environment -- let's be frank: America in general -- fosters a casual attitude toward obesity and ignorance of its impact on individuals, families, and the nation.
Despite its extraordinary consequences, a 2009 University of Chicago study found that most Americans are not seriously concerned with obesity. Although more than half of us are overweight, the study authors said that less than 25 percent of the 909 adults they surveyed saw their own weight as a serious or very serious problem.
It's hard to pinpoint any one reason for the obesity epidemic, said Dr. Jeffrey P. Koplan, director of the Emory Global Health Institute at Emory University in Atlanta. "Our daily lives and environment have changed significantly over 50 years," he said, "creating an environment that is more favorable to taking in excess calories and getting less exercise. Portion size, snacking, how and when we eat, who we eat with, how food gets prepared -- there's a bundle of issues there, virtually all of which promote eating when we don't need to, eating the wrong things, and eating too much."
Add to poor eating habits our reduced opportunities for even simple exercise in the course of our day -- how many of us actually walk or ride a bike to work? -- and Koplan said the increase in obesity and type 2 diabetes is no surprise.
What may surprise you is the food industry's role in manipulating our eating habits and undermining the most determined of our New Year's resolutions to lose weight.
Writing in the Journal of the American Medical Association, Koplan and Kelly Brownell, from Yale University's Rudd Center for Food Policy and Obesity, observed: "Billions of dollars have been spent convincing individuals (children in particular) that highly sweetened beverages and cereals, salty snack foods, and a vast array of products high in fat, sugar, and salt are fun, athletic, sexy, popular, healthy, and even have beneficial properties."
Geralyn Spollett calls the ramped-up fat, salt, and sugar the food industry's "Golden Triangle." The American Diabetes Association president said: "You get enough fat, salt, and sugar in something and people will crave it." In fact, a 2009 Scripps Research Institute study found that over-consumption of fast food "triggers addiction-like neuroaddictive responses." Spollett said: "The whole push of the food industry towards having people eat more, and eat the wrong kinds of foods, is rampant in the U.S., endangering people at genetic risk for obesity."
NUTRITION REFORM NEEDED
Rebooting our own unhealthy eating and exercise habits -- and achieving what we might call nutrition reform for the nation as a whole -- will take a multi-sectoral effort.
"It starts with nutrition," said Spollett. Perhaps the most basic choice we can make about our nutrition is in the language we use to describe it. Spollett said, for example, that rather than "go on a diet," we need to think in terms of a "meal plan," or simply "healthy eating." A short-term diet will only be as good as the short term. "What is needed is lifelong change," she said.
- Type 2 diabetes results from the body's inability to effectively metabolize glucose in the bloodstream. Type 1 diabetes is caused by the inability of the pancreas to produce the insulin needed to keep the blood glucose level balanced.
- Half of all people with type 2 don't know they have it.
- The condition can sometimes be managed with changes in diet and activity level. When that's not enough, a daily regimen of blood-taking, drugs, and possibly insulin injections will be needed to maintain a normal blood sugar level.
- Although there is a genetic predisposition for type 2 diabetes, the vast number of cases are the outcome of poor diet, obesity, and a sedentary lifestyle.
- The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) estimates that 8.3 percent of the American population had diabetes in 2010, including 18.8 million who had already been diagnosed and another seven million who didn't know they have it.
- NIDDK estimates that as many as 79 million American adults over age 20 -- including half of adults over 65 -- have pre-diabetes, abnormal blood sugar that increases their risk for type 2 diabetes, heart disease, and stroke.
- People of color have the greatest risk and rate of type 2 diabetes. One-third of American Indian adults in southern Arizona have been diagnosed with diabetes. Compared with non-Hispanic white adults, the risk of being diagnosed with diabetes is 18 percent higher among Asian-Americans, 66 percent higher among Hispanics/Latinos, and 77 percent higher among non-Hispanic blacks.
- A 2009 study by the University of Chicago forecast that the number of Americans living with diabetes will nearly double, to 44.1 million, in 2034 -- even if the prevalence of obesity in the country doesn't increase, as it has been doing year after year.
- Spending on diabetes will almost triple in the same period, rising from $113 billion in 2009 to $336 billion in 2034. Medicare spending alone will jump from $45 billion to $171 billion.
Spollett tries to help her own patients find a comfortable balance of eating and activity. "You can have an occasional ice cream or piece of cake," she tells them. "But make it part of your afternoon outing while riding your bike, balancing off the activity so that maybe at the next meal you don't eat your total calories, taking into consideration that you had extra calories in the afternoon."
The main thing is to provide enough information so people can make wise choices and recognize the health cost, said Emory's Koplan. He pointed out that the cost isn't borne only by the individual. "If a male dies at 45 of a heart attack," he explained, "or a woman at 55 has a stroke and is disabled, that affects families in different ways. And it affects communities in the cost of health care."
To address the massive and growing diabetes and obesity epidemics, Koplan, a former director of the Centers for Disease Control and Prevention (CDC), said the government can help "level the playing field" by, at a minimum, ensuring the public has access to factual nutritional information and the food industry factually markets its products. He prefers to see a partnership between government and the food industry. "Going to war with each other is probably not in anyone's interest in the long run," he said.
Others, however, argue that we are already at war with a powerful enemy: the illness and death caused by the consequences of obesity, including type 2 diabetes, driven by an inadequately regulated food industry.
A 2009 Urban Institute study recommends using the kinds of "aggressive public policy interventions that helped bring down tobacco use," such as slapping taxes on fattening food; placing simple graphic nutritional labels on the front of packaged foods; requiring restaurant chains to put nutritional information on their menus; and banning advertising of sugary food to children.
Clearly, gaining the public's support for nutrition reform will require major cultural changes in how we think about food. It will also require a fundamental shift in how the health care system cares for people with or at risk for obesity or type 2 diabetes.
"Our health care system isn't working," writes Sara Sklaroff in the January 2012 Health Affairs. "It is more willing to pay for someone with diabetes to have a leg amputated than for the education, treatment, and support that would have prevented the loss of the limb." The 41-year-old Sklaroff, living with type 2 diabetes herself, said that reinventing diabetes prevention and care could mean insurance companies paying for sessions with trainers or physiologists who could teach and support good exercise habits.
Cooking classes that teach people how to buy and prepare nutritious food at an affordable cost would be seen as primary prevention for obesity and diabetes, even secondary prevention for helping people with diabetes to be aware that what they eat and drink is an essential aspect of managing their illness.
Essential public education campaigns also will be needed, starting with one to kill the lie that unhealthy food -- also known as junk -- is cheaper than healthy food. New York Times Magazine food columnist Mark Bittman demolished the myth of "cheaper" junk food in a September 2011 commentary in the newspaper. He calculated that to feed a family of four at McDonald's costs a minimum of about $23 -- compared to only $14 for a home-roasted chicken with vegetables, salad, and milk, or a mere $9 for canned beans with bacon, green peppers, and onions.
"The real challenge," said Bittman, "is not 'I'm too busy to cook.' In 2010 the average American, regardless of weekly earnings, watched no less than an hour and a half of television per day. The time is there." The "core problem," he observed, "is that cooking is defined as work, and fast food is both a pleasure and a crutch."
Every step we take toward nutrition reform -- in public policy, food industry practices, and our own eating and exercise habits -- will contribute to building a healthier us as well as a stronger U.S. But as with other substances of abuse, breaking our addictions to excessive fat, salt, and sugar -- the culprits in obesity and drivers of diabetes -- will require discipline, education, and positive reinforcement.
Reframing type 2 diabetes -- and the obesity and sedentary lifestyle that most often triggers it -- as potentially deadly but almost entirely preventable is a good beginning. Offering factual information to someone diagnosed with diabetes about how to possibly reverse their disease is every bit as important as writing prescriptions for medications and blood glucose test strips. Even those who have to live with type 2, because of their particular metabolic makeup or other contributing factors, can still largely define what living well with diabetes looks like for them.
For them -- really for all of us in our fat-creating country -- Geralyn Spollett said the American Diabetes Association offers three key messages: "We have good tools to help you take care of yourself. This is a self-management disease, so you have to focus on it every day in terms of your activity level, what you eat and your medications to keep yourself healthy. The more you know about diabetes and apply it to your life, the better off you will be."