Our expert answers 3 Questions
So much of what makes people sick these days is preventable with a healthy diet and regular exercise. But a healthy diet is not easy or free, nor is it without side effects. I spend a lot of time wondering what it would it take for our society to dramatically decrease the prevalence of lifestyle related chronic illness. This is not so much an individual behavior change question but more of a system and population level question with critical unanswered implementation questions related to the massive scale of the problem.
While most people agree that the medical establishment plays a critical role in helping patients adopt and maintain a healthy lifestyle, most also acknowledge the limitations. Most doctors are frankly not experts in diet and exercise science, many don’t believe that lifestyle interventions work anyway, and very few are trained in counseling for behavior change. Even for those who have these skills, the reimbursement structure does not allow physicians to focus a lot of time on lifestyle counseling. There is considerable evidence that group lifestyle counseling led by trained lifestyle coaches can be effective and this is obviously much less expensive than one on one physician based counseling. But, it is difficult for patients to attend weekly scheduled in person group based lifestyle change sessions. Internet mediated or cell phone mediated lifestyle change interventions are a hot topic, but we don’t really have a handle on what factors predict efficacy, engagement, and retention in these programs. Should health systems run these programs? Should insurance companies pay for them? Should patients have some skin in the game with a co-pay or some other incentive structure to encourage engagement and retention. Who should be targeted? Only very high risk patients, such as those who already have heart disease and diabetes, or those who have pre-diabetes and other risk factors, or everyone including those whose who are in the normal weight range and want to stay that way?
We have overwhelming evidence that relatively modest weight loss resulting from improvements in diet and exercise habits can prevent Type 2 diabetes, much in the way that colonoscopies prevent colon cancer and immunizations prevent cases of measles. I am increasingly seeing patients in my own clinic who have Type 2 diabetes, plus a whole host of other obesity related illnesses including NASH liver disease, cardiovascular disease, renal failure, stroke, arthritis pain, and mobility impairment. While we tend to see metabolic syndrome as a risk factor for future disease, I am increasingly seeing something in my clinic that I call “end stage metabolic syndrome.” I also am seeing evidence of slow but irreversible progression to multi-system organ failure in more or less ambulatory, and relatively young individuals who, with a little help and support at an earlier stage, might now be healthy with the potential for a long and productive life. This is a missed opportunity for preventive services. We have a lot more work to do to make it easy and effective for individuals to engage in a diabetes prevention focused lifestyle intervention but the payoff has the potential to be enormous for the health system and for public health. I want to be part of an effort that cuts the prevalence of Type 2 diabetes in half over the next 20 years in the United States. Along with diabetes, we will see prevalence estimates of numerous other obesity related chronic illnesses decrease if we are successful.