Diabetes Futures

When I was a health science student I remember learning about the old time practice of tasting urine to detect a fruity taste indicating diabetes. During that lecture green students would become green with nausea contemplating a bygone era incomprehensible in our modern sanitation sensitive world. We have come a long way in measuring and treating diabetes in more sophisticated ways.

While testing and treatment have advanced, the actual frequency of diabetes has continued to rise in dramatic fashion. Projections on the rise in diabetes are based on sophisticated statistical methods. While many people die from diabetes, many people with diabetes die from other things, meaning that our most complete measure of the population’s health, the death certificate, is not a valid measure of the overall prevalence of diabetes. Though diabetes can be a ravaging disease if not managed well, often people with diabetes die from other things. This can be either because the disease contributes to other chronic illnesses, like coronary heart disease, which become an immediate cause of death, or because improved treatment prolongs life enough for diabetes patients to succumb to unrelated diseases like cancer.

After death statistics, the next consideration is the number of people sick. We don’t do as well with nonfatal illness counting. We try to extract data from a very disconnected health care system. These efforts include the National Health Interview Survey, the Health and Nutrition Examination Survey, the Behavioral Risk Factor Surveillance System, the National Ambulatory Health Care Survey, and the National Diabetes Surveillance System. Diabetes is included in all of these data collection systems because it is such an important health problem, effecting one in ten adults (diagnosed). However, even with all these data sources, there is still an element of uncertainty: we don’t have a data system which captures the actual health care records for all people diagnosed with diabetes, and certainly not for the thousands of people undiagnosed.

With these caveats on the current extent of diabetes, there is now a projection that diabetes will increase from about 1 in 7 adults(diagnosed and undiagnosed) in 2010 to between 1 in 5 to as high as 1 in 3 by 2050. Several factors are attributed for the increase. First, the population is living longer, and more elderly life spans means more diabetes. Next, treatment is more effective, so that people with diabetes are living longer, inflating the sub-population with the disease. In addition, the groups in the population with higher rates, such as Hispanics and Pima Indians are growing at a rate faster than the general population. Finally, the increase in obesity in the population is directly related to the increasing diabetes prevalence, including the growing count of children and teenagers having what used to be called “adult-onset” diabetes.

The only reason to measure these trends is to guide plans to intervene. Are we doomed to a third of adults having to manage diabetes? Of course screening and treatment could improve, so that a higher proportion of diabetes patients can live otherwise normal lives. It might be that in the future, diabetes consequences will be less frequent, less severe: even though more people will have diabetes, there could be fewer people suffering diabetes blindness and amputations.

The current state of the art with diabetes health promotion leaves much room for improvement. For decades we’ve tried ways to help people follow diabetes-specific diets, practice healthy foot care, take medication correctly, and prevent diabetes-related damage through physical activity and weight management. This work will continue, but increasingly there will be a search for policy solutions which bypass the messy business of trying to change people’s behavior.

I've become convinced that the most promising frontier for diabetes prevention as with all health promotion, is the creation and establishment of policies which change the food and exercise environment.  There is much work to do to determine whether a given policy works, to navigate the political system to make it possible to apply the policy, and to do long term evaluation to be sure the policy is having the intended effect without undesirable unintended consequences.  Sometimes policies will be seen as antagonistic to free markets, but sometimes policies will give rise to entrepreneurial opportunities.  Long term sustaining of policies will be more assured if we can create a win for all involved.