Diabesity: A Wake-up Call for Medicine
By Lynn Hawkins
Once upon a time, humans roamed the earth without fast food, cheese-whiz, and Tastycake delights. These were the days where your transportation came attached to your ankles, work often involved the use of more body parts than the fingertips, and you actually had to walk up to television to turn the channel. Luckily, we have escaped such mid-evil conditions to elevate ourselves, at least in terms of waist-size, BMI, and time spent residing on the gluteal muscles. Which, ironically, puts us back into mid-evil times, for in both periods being overweight signifies a life of little physical work and too much food to eat. The difference is that whereas this applied only to the royal elites in days of old, in 2003, 60% of American adults have become the "royal elite." Moreover, while mid-evil pudginess was revered and admired, we know today that extra weight carries with it health risks from heart disease to diabetes.
The numbers are staggering. Close to two thirds (64.5%) of adults are overweight (BMI > 25) and one third (30.5%) are obese (BMI > 30). In the past four decades, the percent of obese adults has more than doubled, with most of the increase occurring in the past twenty years. In 1991, four states had obesity rates of 15-16%, with all other states below 15%. In 2000, all but one state had obesity rates greater than 15%, while 22 states had climbed to 20% or higher. For minorities, especially women of color, the rates of those overweight are fast approaching 80% (1).
Concurrently, but not surprisingly, non-insulin dependent diabetes (NIDDM) has risen steadily over the past decades, despite estimates that only one of every two cases remain un-documented (2). Four of ten U.S. children born right now will develop diabetes in their lifetime if the current trend continues. Already, one in ten adults over the age of twenty has diabetes. For minorities, the rates are even higher.
It does not take rocket science to connect the two. In fact, 70% of non-insulin dependent diabetes risk in the U.S. is attributable to excess weight (3). Children, a population in which both NIDDM was previously absent, elucidate the connection, as the rapidly rising prevalence of overweight adolescents (having tripled in the past two decades) has correlated with the simultaneous explosion of children developing NIDDM. Yes, diabetes and obesity have joined forces to become the medical Goliath of the 21 st century, "Diabesity".
Possibly the most troubling aspect of the problem, however, lies in the philosophy with which medicine confronts the problem. While geneticists scurry frantically to find the "magic gene", drug companies look for the "magic pill", and physicians wait for the two to blend into the "magic treatment", we continue to lose ground on diabesity. We must wake up to see the fundamental problems with our current approach to this (and most) disease if we are going to reverse these numbers. More profoundly, decreasing rates of diabetes and obesity are the only "magic" to be sought; common sense, not medical miracles will provide the means to the solution. Here are four aspects where medicine falls short in its approach to diabesity, with implications for other prevalent conditions in our society related to an over-indulgent sedentary lifestyle.
How does medicine determine success or failure?
Back in elementary school, teachers would show you were wrong, at which point you could begin to erase and fix the problem. If medicine had such a teacher, the equation to consider would look like: If medicine treats disease X, and disease X is on the rise despite increasing amounts of research, public education, and treatments, than you need to get out the eraser. The numbers above show clearly that the current approach to diabesity is failing patients, and until medicine assumes accountability, it will remain as that student who sits in ignorant bliss, but with the wrong answer. And patients will suffer as the epidemic grows.
Reductionism does not confront complex lifestyle-related conditions
In the classical allopathic approach, the astute clinician works to discover the single microbe, single anatomical explanation or equally precise cause of disease. It works well when the most pressing medical conditions are TB, pneumonia, and other infectious disease. Unfortunately, in a country where chronic disease dominates, medicine fails to address conditions like diabetes and obesity effectively, both because they do not have a simple one-cause etiologies and because they do not exist as distinct phenomena. The fact that one involves insulin resistance while the other does not should not relegate the two into separate categories of disease; instead, their key similarity - co-inhabitance in the human organism - implores medicine to address diabesity, not distinct conditions of diabetes and obesity.
If genes and drugs are not the cause, they will not be the answer
Can you recall anything within Darwin's dogma that could explain, using genetics, how our population has suddenly fallen to diabesity like never before? Darwin would have looked at the overnight doubling of rates of obesity and exclaimed, "Can't be genetics!" This is not to say that there is no genetic component to either condition, not to say that genetic research, along with the Genome Project, will not eventually enable physicians to better identify those at risk for these conditions. However, when you hear lecture after lecture, read article after article describing the suspense, the adventure of this manhunt for the answer to these problems, to be found in double-helix form, or within a cute little capsule, the disconnect becomes apparent: We are trying to solve a problem that is obviously behavior/lifestyle induced by other means (i.e. genetics, pharmaceuticals), willing to ignore the causal factors as "unchangeable variables." Medicine, based on its focus, acts as if it is a congenital shortage of drugs or a genetic defect that is to blame for diabesity. Until we address the direct causes, we will sit mesmerized by the latest, most astute geneticist or drug company as they explain that day's answer to diabetes. And America's collective blood sugar will escalate, its waist continue to enlarge.
Prevention is still the best medicine
A book of Clinical Epidemiology states in a matter-of-fact way, "Most effort [by physicians] is spent on tertiary prevention, less on secondary prevention, and least on primary prevention. (4)" In the context of this issue, medicine would rather treat vascular disease, neuropathy, and blindness (symptoms of chronic diabetes) over those with early signs of insulin resistance, syndrome X. And for all of those not in these categories, medicine has little interest (i.e. no billing/economic interest). Unfortunately, within this paradigm least attention is given to those with the most to gain from intervention, those with decades of healthy living ahead of them. Until medicine understands that preserving and maintaining health are paramount to treating end-stage disease, it can only improve in its technical and scientific ability to the latter, an attack that will prove futile against the army of factors causing a rise in lifestyle-related disease. Medicine must counter such factors by causing a rise in lifestyle-related health , not by watching as disease develops before acting. Simply put, insofar as medicine concedes all but the treatment of disease, it cannot - and will not - improve health.
1) "Statistics related to overweight and obesity, based on NHANES II data". Found on http://www.niddk.nih.gov/health/nutrit/pubs/statobes.htm.
2) National Diabetes Information Clearinghouse "Diabetes in America, 2 nd edition" 2002. Found on www.niddk.nih.gov/.
• National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes Prevention Program Meeting Summary. August 2001. Diabetes Mellitus Interagency Coordinating Committee.
• Fletcher, R et al. Clinical Epidemiology - The Essentials. Williams and Wilkens. 1988:158.