July 19, 2016

Challenges of Preventing Diabetes

Edward C. Chao, DO, is a doctor practicing in the VA San Diego Healthcare System and is an associate clinical professor of medicine at the University of California, San Diego. He is the author of the article I am using for this blog.

Preventing the potentially devastating and often irreversible complications of diabetes, or better yet, keeping the condition itself from even developing, is far less burdensome for patients, costs less to the health care system, and leads to a better quality of life for patients. So, why are increasingly alarming numbers of patients developing prediabetes or diabetes? With all the knowledge we now have, where are we coming up short? Why?

We have all heard about the proverbial frog in boiling water. If you drop it in to a pot, it will take decisive, quick action, as it sees the danger; it will jump back out immediately. But if the water is gradually heating up, the frog does not appreciate the risk as keenly. I think patients and diabetes professionals alike sometimes tend to see diabetes this way. It is human nature.

The latest estimates say that 86 million Americans are considered to meet the criteria for prediabetes. The scary part is 90% do not know it. Without delving into the debate over whether this should be considered an entity, can't we be proactive and stem the tide before someone develops type 2 diabetes and add to the 25% of individuals who revert to normoglycemia?

We have read and heard about studies such as the Diabetes Prevention Program (DPP) and several others that show the superiority of intensive lifestyle intervention over metformin for preventing diabetes. What stops our patients from succeeding like the participants in these trials? Here are 3 possible reasons.
  1. It is not in our (human) nature. We sometimes do not take the long view or consider the big picture. It is all too easy and necessary to focus on what's at hand: the daily stresses and challenges of work, taking care of our families, paying our bills, and maybe sometimes, taking just a tiny slice of vacation to relax. Who has the energy or the time to try to avoid a disease that may not be diagnosed or, if so, may show up years down the road? “I'll worry about that later. I have too many things on my plate, and I just don't have the time to deal with all of that right now” or “That won't happen to me.”

    For those with diabetes, some may approach the future with a similar attitude of avoidance. If a patient does not feel any differently when his or her glucose is 200 mg/dl or 300 mg/dl, why spend all of this time testing or performing any of the other multiple self-management tasks that are so crucial to living well with diabetes?

    Additionally, we as a society generally are used to and tend to gravitate toward the quick solution, instant messaging, same-day delivery for packages, seeing 50 “likes” on our Facebook page posts within minutes of updating our status. If we run into trouble, we sometimes think: “There's a pill for that.”
  1. These studies looking at prevention took place in a different setting, with intensive lifestyle changes complemented by close monitoring and support. But what about translating this to the real world, to the communities in which patients live? Some components of large clinical studies on preventing diabetes, such as intensive lifestyle intervention implemented in the DPP, can be challenging to apply in communities. In one study, Dr Ackermann and colleagues randomly assigned 509 low-income individuals with prediabetes who were overweight or obese. After attending several lessons of the DPP adapted to the YMCA, the mean weight loss at 12 months was 2.3 kg greater for the intervention group vs the standard care cohort. For the 40% of participants who completed 9 or more sessions, the weight loss was 5.3 kg more than those who received standard care.
  1. Health is not just the absence of disease or feeling unwell. We must change our mindset, as individuals and as society as a whole. This speaks to the idea of emphasizing the process rather than the product or end goal. Many of us tend to put our focus on the 25-lb weight loss or reaching a target HbA1c of 7.0%. But what about the steps that we have to take daily to make achieving these targets a reality? I heard an analogy once that asked, “What if I gave you a car that was brand new and in perfect condition? It looks and runs great. If anything happens to it, whether it's a scratch or a crash, that's it; you don't get to trade in for a new one. Knowing this, how would you look at it? How would you treat it?”

    We must start viewing our health in the same way. We must expand our mindset not only to stamp out diabetes, but to prevent it from even occurring. We can stem the tide and avoid heading down the road towards 1 in 3 Americans with diabetes by 2050. Individually and collectively, we need to both think and act differently. Unquote:
It is obvious from my blog here that the medical community thinks differently and are worried about over diagnosis and causing anxiety in patients. This was not available to me before my diagnosis of type 2 diabetes, but I sure wish it was. I could have done something possibly to have lessened my fight to manage my diabetes.

What is even scarier is that prediabetes is increasing among healthy weight
American adults. See this short article about the percentages as we age.


Denise said...

I would give almost anything to have been given notice before I developed full-blown diabetes, along with dietary and exercise support.

Bob Fenton said...

Denise, You have expressed what many of us with diabetes wish we would have been informed of and have been given a chance to battle diabetes earlier. Even many of us with diabetes in our family history would still have done more if we were given the chance rather than being diagnosed late and struggling to manage our diabetes.