On Preventable Chronic Disease

In both my professional and my academic pursuits, I have begun to cultivate an interest in public health policies relating to (primary) prevention medicine and public health (long-time readers will no doubt recognize the turn in some of my posts in the last six months or so).  I have noted several times that U.S. health care and research resources are woefully misallocated, with only tiny percentages of both care and research dollars going to preventive medicine and public health even while there is little dispute that such measures are far more likely to have a significant impact on population health than what we allocate the lion's share of resources to (acute care and development of new technologies and biologics). 

I was therefore interested to note the release of a Milken Institute report that quantified the cost of preventable chronic disease in the U.S. in 2003 at $1.3 trillion.  As Greg Dahlmann notes over at Bioethics Blog, "even if the Milken people are off by half, it's still an enormous number... something like 5% of GDP."  I was recently thinking about the Diabetes Prevention Program* (DPP), which found, in the release of its findings in 2002, that behavioral interventions, primarily intensive counseling on diet and exercise, reduced the subjects' risk of developing diabetes by over 58 percent.  According to the NIH website:

This finding was true across all participating ethnic groups and for both men and women. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. About 5 percent of the lifestyle intervention group developed diabetes each year during the study period, compared with 11 percent in those who did not get the intervention.

[ . . . ]

Participants taking metformin reduced their risk of developing diabetes by 31 percent. Metformin was effective for both men and women, but it was least effective in people aged 45 and older. Metformin was most effective in people 25 to 44 years old and in those with a body mass index of 35 or higher (at least 60 pounds overweight).

In other words, counseling about diet and exercise was astonishingly efficacious in reducing the risk of developing type II diabetes: "The DPP's striking results tell us that millions of high-risk people can use diet, exercise, and behavior modification to avoid developing type 2 diabetes."  Yet, amazingly, the findings of the DPP have yet to gain any significant traction in health centers or public health policy.

Of course, most competent health care providers will advise pre-diabetic persons to diet and exercise, but despite clinical practice guidelines urging that providers strongly recommend such intensive counseling, it has yet to infiltrate clinical care in any widespread sense.  In addition, many payors do not cover or reimburse for such counseling, and the preference for biologics as a remedy for any and all ailments is pervasive among both providers and patients (the notion that such a preference is actively inculcated by industry and private sources who have a vested interest in sustaining and feeding such preferences is also relevant here). 

The weak public health infrastructure is also partly responsible for the absence of thorough and widespread evidence-based public health policies involving the findings of DPP.  Lost amidst the sound and fury of the debate over access to care is the importance of our unjustifiable allocation decisions regarding primary prevention, particularly of chronic disease.  As Dahlmann reminds, the problem must be viewed in its human terms as well as its economic ones: we are talking about widespread, eminently preventable human suffering.

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*An immediate family member is one of the approximately thirty principal investigators for the DPP.  However, the opinions reflected in this post are mine and mine alone. 

Comments

[Patrick S. O'Donnell]

Daniel,

I can personally attest to the importance of being well-informed (although I don't know if I could call it 'intensive counseling') about the risk of type 2 diabetes, which runs strong throughout one side of my family and has afflicted one of my brothers (as it did our father, his mother, an uncle...). My doctor, having learned something about my family history, told me of the sorts of things I needed to do by way reducing my risk for adult-onset, type 2 diabetes. And of course the fact that I was considerably overweight (despite regular exercise) concerned him, as well as the fact that heavy alcohol consumption was one of the pre-diabetes practices that was often found in my family. He advised me on the importance of reducing my weight (i.e., largely eating less, which was difficult to do, as my diet had been nurtured over the course of many years working labor-intensive jobs, and the transition to academic work meant a much more sedentary lifestyle that now required more deliberate exercise than I was used to), increasing my exercise regimen a tad, and drinking much less alcohol than was custom among some in my family. I've slowly but steadily taken this advice to heart and, at least to this point, have not become diabetic. I realize there are no certainies here, but I do think the doctor's serious and pointed remarks to me on this score have had a salutary effect (alongside some stories my wife brings home from her job at the local hospital), and for that I'm quite grateful. And while I suspect that at present some forms of alternative medicine are structurally better suited to a "preventative" approach to health care, that in no way rules out the fact that we do appear to have a moral (we 'ought' to do it) and political obligation (because we 'can' do it) to formulate and institute widespread evidence-based public health policies geared toward *primary prevention* and thus make considerable progress toward reducing the incidence, as you say, of such "eminently preventable human suffering."

[Not directly on point, but this moving story of one person's recent discovery that he has diabetes ties in with Frank's recent posts here and at Concurring Opinions about health insurance: http://www.latimes.com/business/la-fi lazarus7oct07,1,3054944.column?coll=la-headlines-business]

[Daniel Goldberg]

Well said, Patrick, and thanks for sharing your personal narrative. The more I think about this, the more problematic I find our current allocation policies to be. And of course, studying the history of medicine and public health only reinforces the nature of the problem, because allocating funds based on disease burden and on population health has virtually never been an objective or a reality of allocation matrices in the U.S.

[George]

Daniel thanks!
Thanks for opening up to us! It is really strange to your family history.