Volume 12 Number 3, 1999, Page 180
Hallucination or Vision: Can We Prevent Type 2 Diabetes?
Christine A. Beebe, MS, RD, LD, CDE
Editor's note: This article was adapted from an address of the American Diabetes Association President, Health Care and Education, given in June 15, 1998, at the Association's 58th Annual Meeting and Scientific Sessions in Chicago.
If you have diabetes, have a loved one with diabetes, or provide care for people with diabetes, you must on occasion have a vision of what life would be like without diabetes. That vision is fueled by the hope that a cure is possible if all the right things happenresearch, technology, medicine.
Occasionally we feel that our vision is nothing more than a bizarre hallucination. Diabetes is so complicated, the problem is so overwhelming, that finding the cure is unimaginable.
Webster's Dictionary defines hallucination as "an illusion," something that is not present. Currently, a world without diabetes is not present. In fact, diabetesparticularly type 2 diabetesis growing at an alarmingly rapid rate. Type 2 diabetes has indeed been identified as an epidemic and a public health problem.
The American Diabetes Association has a vision in its mission "to prevent and cure diabetes and to improve the lives of all people affected by diabetes." Researchers around the world are working on a cure, while we as health professionals are trying to make an everyday difference in the lives of people with diabetes. But can we do anything to prevent diabetes? Many of us do believe we can prevent type 2 diabetes, that it is not a hallucination.
It has been said that the only difference between a hallucination and a vision is the number of people who see it. Each of us must see this vision and help others see it, for we cannot do this alone. Yet, the American Diabetes Association must take the lead in preventing diabetes, particularly the growing epidemic of type 2 diabetes.
We need to approach preventing type 2 diabetes with three essential elements in mind. First, we must recognize that type 2 diabetes is the result of changes in lifestyle that have occurred gradually with technological advances. Second, we must acknowledge that the realities of changing a person's lifestyle are multidimensional and complicated. And third, we must accept that the Association, and particularly health professionals, must play the pivotal role in leading this effort.
The prevalence and incidence of diabetes has grown 500% in the United States since 1950. The incidence of type 2 diabetes is expected to nearly double worldwide by 2010, from 119 million to 213 million people.
Why is this happening? As we all know, diabetes develops as a result of a yet-to-be-understood interaction between genetics and lifestyle. Specific lifestyle behaviors, such as changes in diet, reduced physical activity, and the alarming worldwide increase in obesity, have been implicated as responsible for the rise in type 2 diabetes. It has been termed "urbanization," "Westernization," and even "Coca-Colanization." Nonetheless, it is the good life: an abundance of food and the technology to decrease our physical work load.
Outside of genetics, obesity is the number one risk factor for type 2 diabetes. If the trend toward gaining weight does not change, researchers estimate that 100% of the U.S. population will be obese by 2030. In considering this, our vision to prevent type 2 diabetes must include modifying lifestyles to prevent and treat obesity.
When we consider the magnitude of changing an entire country's lifestyle, it does appear to be a hallucination. We can't ask people to go back, to trade their cars for bikes, to grow their own food, and to forgo even an occasional Big Mac. We must realize, however, that there is no one single cause for obesity. Our environment has changed, but we can also change our environment. It will take a nationwide mobilization of resources and each of us being proactive to facilitate that change.
To start, we need to think in terms of people. I would like to tell you about one of my favorite patients, James King, and his family. They are typical of Americans at greatest risk for developing type 2 diabetes. Mr. King is African-American, 62 years old, and has had type 2 diabetes for 12 years. He is overweight with the typical pattern of upper-body fat distributiona waist greater than 1 meter. He is a carpenter who owns his own business.
He has seven children. Most of them have upper-body obesity and thus are at high risk for developing type 2 diabetes. Can we prevent this second generation from developing type 2 diabetes? Recent research suggests that diet and exercise changes that produce as little as a 4.5-kg weight loss are associated with a 31% lowered risk of developing type 2 diabetes in individuals with a family history of the disease.1 The nationwide Diabetes Prevention Program currently underway should give us more insight and perhaps further proof that weight reduction and lifestyle changes can delay or prevent the development of diabetes.
What about Mr. King's grandchildren, the third and fourth generations? Can we prevent them from becoming obese altogether? Clearly, we would advise them to adopt a low-fat diet. Americans have heard this from every source: the media, health professionals, health organizations, and numerous others. Fat is more dense than either carbohydrate or protein, fat has a lower satiety value than carbohydrate, and fat has been shown to stimulate overeating.
The most recent data from the United States Department of Agriculture (USDA) suggests that Americans are responding to this message. Fat as a percentage of total calories decreased from 44% in 1968 to 33% in 1995. We have not yet reached our nationwide goal of <30%, but the change has been substantial.
Why, then, during the same time period have we seen the incidence of obesity rise from 22% to 33% of the population? And if we apply the most recent suggestions that overweight begins at a body mass index (BMI) of 25, fully 54% of Americans are overweight and at risk for developing diabetes.
Not surprisingly, Americans want to believe that there is one simple answer and that is to reduce fat intake. Continual overconsumption of dietary energy in relation to daily needs leads to obesity. While an increase in dietary fat increases the tendency to overconsume, there is considerable controversy regarding whether increasing dietary fat intake leads to obesity. Population studies show a correlation between obesity and fat intake but they do not control for differences in physical activity.2 Controlled studies in humans do not show an increase in BMI with increasing fat intake, provided that calories are held constant.3
Here in the United States, we see that during the same time period (1985 to 1995) in which the percentage of fat decreased, mean total caloric intake increased by >100 calories/day (Table 1). Total grams of fat consumed has gone down only a few grams/day. Thus, Americans are consuming more calories as carbohydrate.
The USDA food pyramid guidelines suggest that indeed the majority of our intake should come from carbohydrate foods, those at the bottom of the food pyramid, such as whole grains, cereals, fruits, and vegetables that provide fiber, chromium, magnesium, vitamin E, and many other nutrients found to be important to glucose tolerance and health.
Unfortunately, Americans are obtaining their carbohydrate from the top of the pyramid. People consuming a diet <30% fat consume more carbohydrate as juice drinks and carbonated beverages than those on a higher fat diet (Table 2).
Why? I believe it is because in our effort to simplify the message to the public, we have misled Americans into believing that fat is the only dietary culprit contributing to obesity. We see the same phenomenon occurring with the recent emphasis on carbohydrates. Americans need to be provided with the entire story, to see the whole picturein this case that total calories are still important and that there is no one quick fix to our health problems. Indeed, I believe we are just on the verge of understanding how both the quality and quantity of food we consume effects risk for developing diabetes, and the answer is likely much more complicated than we have thought.
What about the other side of the energy equation? Our population as a whole has increased caloric consumption, but what has happened to caloric expenditure? Mr. King, our carpenter, is more physically active than most individuals, since he is on his feet, walking, bending, and lifting while working. While this is not the 30 minutes/day of moderate to vigorous physical activity recommended by the U.S. Surgeon General's Report in 1996, he is fortunate to have a greater opportunity to be physically active than do his children or his grandchildren.
His children each have desk jobs where they, like many Americans, sit for much of the day. Instead of walking or riding a bike to work, they sit in their cars or on a train. They return home, eat dinner, watch TV, and go to bed. According to the Surgeon General's report, 60% of Americans are just like this. Only 15% of us get regular vigorous activity at least 3 times/week.
What about Mr. King's grandchildren? Is their opportunity to burn calories any brighter? Fortunately, they live in Illinois where physical education is still mandatory in schools. Many states have either eliminated physical education or reduced the amount of time spent in phys ed class in an effort to save money. At the same time, children are more sedentary, watch more television, and play more video games than ever before.
Such small lifestyle alterations individually and collectively are likely major contributors to obesity and subsequently type 2 diabetes. What can we do, as health professionals who care about people with diabetes and their families? What can the American Diabetes Association do, as an organization composed of some of the most informed and passionate health professionals in the country?
We are experiencing an unprecedented focus on diabetes in this country, and we all want to take the lead in making diabetes a national priority. The association between obesity and diabetes is clearly the most positive association between obesity and a chronic disease. Future generations have so much to gain from health professionals such as ourselves taking the lead in making healthy lifestyles a national priority.
We will accomplish this by forming partnerships with others to attack the problem from all sides. Our partners need to include government agencies, corporations, the food industry, schools and institutions of higher education, and other health-related organizations.
With this in mind, I would like to recommend some ways in which I think we can accomplish our mission to prevent diabetes through our three major focus areas: research, information, and advocacy.
First, we need to continue our efforts to make diabetes research a national priority for the National Institutes of Health (NIH). Furthermore, we must see to it that research includes more studies in nutrition, obesity, and, most importantly, behavior modification. It is a well-known fact that knowledge is not necessarily translated into behavior. More Americans than ever before understand the benefits of exercise to health, yet few of them can find the time or motivation to sustain a regular exercise program.
We need to learn so much more about how to shape behaviors both in individuals and populations. This is especially true for high-risk groups such as African-Americans and Hispanics, for whom cultural and economic factors have a great influence on ability to change behavior.
In keeping with this, we need to stimulate more researchers to submit grant proposals for this type of research. The Association has made a commitment to seek more behavioral research grants and explore a major behavioral study as part of its newest 5-year strategic plan.
But our ability to fund is limited. We need to press National Institutes of Health to recognize this urgent need. In addition, we need to continue to find ways to work with our industry partners to support lifestyle research while still supporting our mission. Recent alliances with Proctor and Gamble and Campbell's have provided research grants to the Association that are earmarked for nutrition-related research. These are important alliances that exemplify win-win situations.
In the area of information, each of us and the Association must take the lead in getting other health organizations and the government to agree on a consistent diet and lifestyle message to Americans. We need to revise our message about the benefits of a low-fat diet to expand it and include the fact that calories do count.
A recent survey conducted for the American Dietetic Association revealed that nearly 70% of Americans feel so confused about nutrition information that they don't pay attention to it. An interesting request by participants was that they wished scientists would wait until they reached consensus on issues before releasing information. They also stated they did not want to know the research findings as much as the details of practical applicationwhat to eat, rather than what to avoid. My challenge to the health professionals in the American Diabetes Association is to pursue strategies to coordinate this effort among government, industry, and health care organizations such as the American Heart Association and the American Cancer Society.
I believe the Association should consider developing new information strategies and programs in the areas of gestational diabetes, children's lifestyles, and corporate wellness.
The majority of women with gestational diabetes go on to develop type 2 diabetes, yet after delivery they are abandoned by the health care system. Generally, they don't see a health professional again until the next pregnancy or a medical problem arises. Meanwhile, body weight increases in direct proportion to the number of pregnancies. These women need support and education as to the role of lifestyle in potentially preventing or delaying type 2 diabetes. And once again, cultural differences should be considered.
Our children are the future generation of people with diabetes. The longer and earlier they are obese the greater their risk for diabetes. We need only observe the alarming rise in type 2 diabetes among children to see that the future is upon us. We do not have to reinvent the wheel in developing a curriculum on diabetes, obesity, and lifestyles for school children. Several groups have already developed lifestyle modification programs for kids. We need to seek them out and form partnerships with them to integrate a diabetes component into their programs. The American Health Foundation and the 5-a-Day Alliance are two groups that already have successful programs.
The 5-a-Day Alliance is an example of organizations and industry coming together to provide a consistent and understandable message. The Alliance's goal is to encourage people to consume five or more servings of fruits and vegetables per day. This behavior has been associated with lower rates of obesity and healthier populations. They have made progress in that Americans have increased their consumption of fruits and vegetables from 3.9 servings in the 1980s to 4.4 servings after 1990. Unfortunately, Americans are consuming 40% of their fruits and vegetables as French fries.
The American Diabetes Association website receives more than 4.5 million hits each month. Many of the consumer hits are diet-related. The Association and health professionals have a unique opportunity to influence many people in this country every day with a consistent message.
We all live in communities that contain businesses. Businesses are interested in preventing diabetes to reduce their health care costs. What a wonderful role it would be for health professional volunteers in the Association to promote wellness to a company in exchange for them participating in an Association fundraising program such as America's Walk for Diabetes or the Tour de Cure, which raise dollars for more research and information programs. We are already doing some of this through Diabetes Alert, but we need a coordinated wellness program to be developed by volunteers.
Finally, in the area of advocacy, we need to do the obvious and continue pressing each of our legislators to increase funding for diabetes research. In addition, we need to work at the state and local community levels to make sure school boards are providing opportunities for children to be physically active and to develop skills for an active adulthood. We need to push our community leaders to develop safe and user-friendly bike paths, walking trails, and other venues for physical activity. I am advocating getting involved in our communities. This not only can help modify lifestyles but also can provide a forum for spreading the word about diabetes.
Now that the costs of diabetes self-management education and supplies are covered for Medicare recipients and many insured people, we need to advocate for care for uninsured people with diabetes. At the same time, we need to be visionaries and advocate for coverage for preventive interventions, such as weight reduction programsat the very least for people at high risk, such as those with a family history of diabetes or with upper-body obesity. Perhaps enrollment in a health club should be a covered benefit in high-risk individuals. Insurance companies should be asked to provide incentives to people who demonstrate healthy lifestyle behaviors.
We will not prevent type 2 diabetes if we do not help Americans change their lifestyles. Changing lifestyles has to occur on many levels, as illustrated by my patient Mr. King and his family. The American Diabetes Association and its volunteers need to lead this endeavor.
Imagine that in 2010 the incidence of type 2 diabetes will not have doubled because Americans will have reduced not only their fat intake but their caloric intake as well. People will be eating more whole grains and less refined foods, more fruits and vegetables. They will be physically activewalking, biking, gardening, using their muscles, watching less television.
Is this a hallucination? As stated earlier, the only difference between a hallucination and a vision is said to be the number of people who see it. We as health professionals who care about the future and about people with diabetes need to help others see this vision.
1Wing R, Venditti E, Jakicic J, Polley B, Lang W: Lifestyle intervention in overweight individuals with a family history of diabetes. Diabetes Care 21:350-59, 1998.
2Bray G, Popkin B: Dietary fat intake does affect obesity! Am J Clin Nutr 68:1157-73, 1998.
3Knopp R, Walden C, Retzlaf B, McCann B, Dowdy A, Albers J, Gey G, Cooper M: Long-term cholesterol-lowering effects of 4 fat-restricted diets in hypercholesterolemic and combined hyperlipidemic men: The Dietary Alternatives Study. JAMA 278:1509-15, 1997.
4Borrud L, Wilkinson EC, Mickle S: What We Eat: USDA Surveys Food Consumption Changes. Community Nutrition Institute, 1997, p. 4-5.
Christine A. Beebe, MS, RD, LD, CDE, is director of St. James Health and Wellness Center in Chicago Heights, Ill.
In a recent Diabetes Spectrum article (Caban A, Johnson P, Marseille D, Wylie-Rosett J: Tailoring lifestyle change approach and resources to the patient. Diabetes Spectrum 12:33-38, 1999), the authors inadvertantly reversed the order of information related to high-density lipoprotein cholesterol in Table 1 titled "Matching treatment intensity to diabetes-related needs based on Weighing the Options criteria" (p. 35).
That row in the table should have read:
Copyright © 1999 American Diabetes Association
Last updated: 8/99