The Real Fight Over Health Care Should Be Against Diabetes and Obesity
In the run-up to the presidential election, the political debate is heating up around Obamacare. As the Supreme Court prepares to deliberate on the individual mandate, the single biggest question is hauntingly absent from the campaign discourse.
How do we stop and turn back the tsunami of chronic disease, in particular, diabesity—the continuum of obesity, pre-diabetes, and diabetes that is the major driver of 21st-century suffering and health-care costs? Diabesity is the hidden cause of most heart disease, hypertension, high cholesterol, stroke, dementia, many cancers (breast, colon, prostate, pancreas, liver, and kidney), and even depression. Yet is it almost never treated directly because there is no good drug for it.
Over the next 20 years $47 trillion will be spent around the world to address chronic diseases caused by diabesity. How our next president addresses this will determine whether or not we bequeath a bankrupt, desperately sick nation to our children, the first generation of Americans who will live sicker and die younger than their parents.
The good news is while we cannot solve problems like war or natural disasters, we can solve diabesity. We haven’t been able to win the war in Afghanistan, but we can win this war on chronic disease. Diabesity is nearly 100 percent preventable, treatable, and very often curable. As Donald Rumsfeld said, this is a “known known.” The science is clear, the strategies well documented (if little applied). Democrats, Republicans, Libertarians, and Tea Partiers alike all have have the potential to get sick and must face this problem square on.
Diabesity affects one in two Americans, yet is not diagnosed in 90 percent of those who have it. In fact, there are no national screening recommendations for pre-diabetes or for persons at high risk for diabetes. The implications of this medical blind spot are staggering—the single biggest cause of chronic disease is overlooked and not treated 90 percent of the time.
Twenty-five percent of those over 65, one in five African-Americans, and one in 10 across the whole population have diabetes. One in three children born today will have diabetes in their lifetime. And pre-diabetes affects up to 150 million Americans. Diabetes alone accounts for one in three Medicare dollars spent. Diabetics cost health plans five times more than nondiabetics ($20,000 vs. $4,000). By 2014, when 16 million more citizens are eligible for Medicaid, the burden of costs will be even greater.
Seventy percent of the federal budget is for Medicare, Medicaid, and Social Security. By 2042, 100 percent of the federal budget will be required to pay for Medicare and Medicaid, leaving nothing for defense, transportation, education, agriculture, environment, or anything else. This is unsustainable. We need a collective, bipartisan national campaign with the passion and vision of President Kennedy’s call to action to put “a man on the moon by the end of this decade.”
The insurance reform at the heart of the Affordable Care Act allows for better access to medical care, including medication and surgery. It laudably promotes improved efficiencies, reduction in medical errors, better care coordination, and implementation of best practices.
But what if we are coordinating the wrong kind of care? What if our best practices are the wrong practices? Our toxic industrial diet, our sedentary lifestyle, chronic stress, and environmental toxins cause diabesity and its attendant downstream ills (often mislabeled as something else, such as hypertension, cancer, heart disease, dementia). Drugs and surgery are feeble, ineffective, costly, and often harmful treatments for lifestyle-induced illness. They are misguided efforts at best, dangerous at worst. Mounting evidence proves that the solution to lifestyle- and diet-driven obesity-related illnesses won’t be found at the bottom of a prescription bottle; they will be found at the end of our fork.
Prescription medication for lifestyle disease has failed to bend the obesity, disease, and cost curves. Statins have been recently found to increase the risk of diabetes in women by 48 percent. And factoring in the increased risk of diabetes when statins are used to prevent first heart attacks, there is no net benefit, and significant potential harm from statin use in the over 20 million Americans who take them.
Avandia, for example, the No. 1 blockbuster drug for type 2 diabetes, has caused nearly 200,000 deaths from heart attacks since it was introduced in 1999. The large ACCORD trial found in more than 10,000 diabetics that intensive blood sugar lowering with medication and insulin actually led to more heart attacks and deaths.
A recent study found that more than 75 percent of stent placements for heart disease don’t help at all to reduce heart attacks and deaths, are harmful, and unnecessarily increase health-care expenditures. Yet the number of angioplasties and stent placements performed has increased, not decreased.
We don’t have “evidence-based” medicine. We have “reimbursement-based” medicine. Doctors do what they get paid to do, not what the science shows they should do.
That’s the bad news. The good news is that there is an extensively studied, scientifically validated set of strategies that work better, faster, and cheaper than medication and surgery and can be implemented at scale with little cost by lay people in local communities and in medical practices.
Intensive lifestyle therapy—not wellness counseling or prevention, but lifestyle treatment of existing chronic disease—focusing on pre-diabetes, diabetes, and heart disease has been proven to work better than medication or surgery. Currently, this is not implemented in our health-care delivery system or in community-based programs in any meaningful way. But it can and should be.
While the individual mandate and insurance reform are the main focus of the debate surrounding ObamaCare, little known but potentially transformative provisions of the Affordable Care Act provide the seeds of change for our entire health care system. These provisions, the National Diabetes Prevention Program (section 10501), Prevention and Public Health Fund (section 4002), creation of community health teams (section 3502), and incentives for states to prevent chronic illness among Medicaid beneficiaries (section 4108), could help stem the tide of chronic disease.
There are plenty of pilot programs, demonstration projects, and examples of the success of intensive, community-based lifestyle programs to improve health-care outcomes and reduce costs. Current provisions for payment and innovation within the health-reform bill set the stage for expansion of these programs.
The Diabetes Prevention Program showed that a structured lifestyle-change program could reduce the progression to diabetes by 58 percent, working better than any other known treatment. The study, published in 2002 in the New England Journal of Medicine, was based on outdated and contraindicated nutritional advice from the old Food Pyramid recommending a low-fat diet for diabetes prevention. The study was performed when bread and pasta were still king, and our government encouraged us to eat 8-10 servings a day of bread and cereals, which are now known to directly drive the risk of diabetes. And yet still, it was more effective than any medication.
This model has been scaled in communities and organizations across America, including a partnership with the Center for Disease Control, YMCA of America, and United Health Group using lay health coaches to implement the program. While the dietary recommendations are still less than ideal, these programs are working. Imagine what a program based on 21st-century nutritional science could do. And these programs have been conservatively documented to save billions.
Over the last few years, a number of examples of the power of community-based peer-support models have emerged. At Saddleback Church Rick Warren, Mehmet Oz, Daniel Amen, and I enrolled more than 15,000 congregants in a lifestyle-change program delivered with online support in small peer-support groups. The church members lost 250,000 pounds in a year, and many reversed diabetes, reduced or eliminated medication, and avoided hospitalization. We changed the culture of the church—changed what was served at bible breakfasts, at work, and at home. Participants learned to create health together—to shop, cook, eat, exercise, and play together. We didn’t treat disease. We didn’t create a weight-loss program. We taught people self-care and how to care for one another, and together they created a miracle—something heath care or health-care reform has not been able to achieve.
Innovative community-based models also can change our default choices for how we live, move, eat, and play. If the things that create health are easy to access and things that create disease are hard to get to, extraordinary change occurs. In Albert Lea, Minn., a pilot project was designed to create healthy choices and limit bad ones. Kids who weren’t allowed to eat in hallways and classrooms, for example, lost 10 percent of their weight. In Thailand, one community garden is irrigated by an old bike hooked up to a generator run by patients with diabetes. They get exercise and grow healthy food at the same time.
This model has been replicated across the world—including Peers for Progress that created pilot programs to treat diabetes in Cameroon, Uganda, Thailand, and South Africa based on peer support. The peer-support-group models were more effective than conventional medical intervention for improving the health of diabetics, and health-care costs decreased 10-fold.
Health it seems happens outside the clinic, where people live, work, play and pray. We need to rethink how we treat chronic disease. It is not only better medical management, which often just barely if at all staves off complications and death, but with high-science, low-cost, high-touch innovations. A comprehensive integrated strategy can solve this problem. Start with revised screening guidelines to identify the 90 percent of pre-diabetics and the 25 percent of diabetics never diagnosed. Build new practice models and reimbursement for group visits to deliver lifestyle medicine in more effective and cost-efficient ways. Support and scale proven community-based peer-support models of lifestyle change. More than 20 percent of Americans are out of work. Train a new army of 1 million community health workers like the barefoot doctors of China who can support their peers in creating health. Set a national goal for America of losing 1 billion pounds in a year.
Retool medical education to train future doctors in lifestyle and food treatment. Support private-public partnerships to create community environments that foster a healthier lifestyle. Fully fund the programs that work (lifestyle change) and stop paying for what doesn’t work (most angioplasties and stents and statin use). Implement the little-known provisions from the Affordable Care Act that can effect change. Prioritize the work of the newly formed National Council on Prevention, Health Promotion and Public Health, an interagency council focused on creating a healthy America outside of the clinic and hospital. Fund these programs, test them, implement them, measure them, and then let the good ones flourish.
We can’t win the war in Afghanistan, and we have been losing the war on cancer, but this is one war we can win. We just need to mobilize.