Effectively Addressing Diabetes
Douglas Tynan PhD., Sidney Kimmel Medical School, Thomas Jefferson University, Philadelphia PA
Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose. Hyperglycemia, also called raised blood glucose or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body’s systems, especially the nerves and blood vessels.
In 2014, it was estimated that worldwide, 8.5% of adults aged 18 years and older had diabetes, an estimate of 422 million people with diabetes. In 2019, diabetes and diabetes related kidney disease caused over 2 million deaths. In addition, raised blood glucose is thought to contribute to 20% of all cardiovascular deaths.
Between 2000 and 2019, there was a 3% increase in age-standardized mortality rates from diabetes. In lower-middle-income countries, the mortality rate due to diabetes increased 13%, and continues to increase each year. In contrast, the probability of dying from any one of the four main noncommunicable diseases (cardiovascular diseases, cancer, chronic respiratory diseases, or diabetes) between the ages of 30 and 70 decreased by 22% globally between 2000 and 2019.
Medical treatment can effectively manage diabetes and in the past 20 years there have been dozens of new effective medications released, over a dozen in the past year approved by the FDA in the United States. Technology related to management including wearable continuous glucose monitors allow patients to track their blood glucose levels and make appropriate changes, and for patient who are treated with insulin, new injection pens, insulin pumps can all improve care. However, despite the improvement in the ability to monitor blood glucose levels and to treat diabetes, the average patient with diabetes has the same average blood glucose level in 2022 that they had in 2002. This is clearly due to difficulty in adhering to medication, diet, and physical activity recommendations. While this lack of adherence is often attributed to individual patients, there are clearly social, environmental, and behavioral factors that impact the ability to take prescribed medication, eat a healthy diet and engage in physical activity. Because has been no difference in population outcome for treatment of diabetes. as rates increase for diabetes in the population, rates for complications have also increased.
Medical advances can be a great help for people but the data on diabetes insist that we do more in the areas of social, behavioral, and environmental determinants of health if we are to make meaningful progress in reversing the trends in diabetes.
In the area of social and environmental determinants, we need to start with healthy diets. That is diets where energy expenditure is balanced by intake, with food that is preferably locally sourced, that is not processed and does not have added salts, sugars, or fats. In many places, healthy foods cost more than unhealthy foods, so programs to need to make certain that healthy foods are locally available, at a reasonable cost. Tastes are learned behaviors that are formed very early in life, and teaching people to learn to eat foods with lower salt, sugar and fats can be a challenge. In some areas, local health workers may be needed to help with distribution and preparation.
Physical activity levels are particularly affected by environmental change. Modern technology is constantly devising ways to reduce physical activity. Urban planning for environments that encourage walking is perhaps the best method to address activity level in large populations. We know that here in the United States that people living in large cities have the highest activity level and lower rates of obesity when compared to more rural areas. In rural areas, people often drive for all services, and rarely walk. Data show that development of trails paths and parks helps to increase activity. Teaching children and adolescents to be active also helps, and the teaching of lifetime activities such as swimming or safe cycling for transportation. Safe environments for activity, social support for physical activity and emphasis on encouraging those behaviors are all essential.
Much of the health promotion literature on diabetes prevention or treatment emphasizes maintaining a healthier body weight. But a healthy body weight is a goal, not a change in behavior. To effectively modify behavior, I would suggest avoiding emphasis on body weight or specific Body Mass Index (BMI) and instead focus on two variables that impact BMI, that is, diet and exercise.
We need an integrated care perspective to tackle the social, behavioral, and environmental determinants of diabetes, and often that requires coordination of existing services, and connecting patients to those services. A collective impact approach starts with identifying improved diabetes care as a common goal for all partner organization in health, education, social and mental health services. This should include grocery stores, pharmacies and other businesses that serve people with diabetes. One organization needs to be identified as the coordinator, the ‘backbone’ organization. That is usually the medical clinic, or a local diabetes advocacy group. Then all partners for food, recreation, pharmacy can have their input and provide information on how to access these services. In many areas of the US, local chapters of the American Diabetes Association provide diabetes education and information to patients on needed, non-medical services. Providing peer support, and ongoing access to diabetes information is essential. To be sure, the patient needs to provide their own care, but we need to provide support, education, and reinforcement for their daily self-care effort. …
Diabetes is the one NCD that is increasing rapidly and has defied improved medical treatment by continuing to cause ever increasing mortality and morbidity. Effective treatment starts not with medication, but the fundamentals of health diet and physical activity for the population. We must understand that changing eating and exercise habits is a difficult task. It requires commitment of both private and government sectors, in areas as diverse as grocery shopping to using parks, to education in schools and in clinics. But until we better manage these two major factors in health, diet, and exercise, through an integrated approach, the numbers of people with diabetes will continue to grow.
Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019. Results. Institute for Health Metrics and Evaluation. 2020 https://vizhub.healthdata.org/gbd-results/
Sidney Kimmel Medical School, Thomas Jefferson University, Philadelphia PA