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Glenn D. Braunstein, M.D. Headshot

Obesity and Diabetes: Research Points to a Better Path

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Been to Disneyland lately? Gotten a gander at a typical family -- young parents, gleeful kids -- from the rear? The evidence of our national obesity epidemic is visible everywhere, from amusement parks and shopping malls to commercial jets where passengers routinely request seat belt extenders as they squeeze themselves into standard 18-inch seats. We may be learning to accommodate our collective excess, but the lifelong health consequences of our bulking up are severe. Let's focus on just one costly, serious companion ailment to obesity: diabetes. These two ills not only constitute epidemics, they combine to create problems that no one can afford to ignore.

This story, including how to save billions in health care costs, can be told in large part by looking at some averages. The average adult man is 5-feet-9 1/2 and weighs 194.7 pounds, the Centers for Disease Control and Prevention says. The average adult woman carries 164.7 pounds on her nearly 5-foot-4 frame.

That's too much, and everybody knows it. The media has reported on the obesity epidemic in America to the point of saturation. And who by now doesn't know that basic to preventive health care are lifestyle changes: lose weight, eat better, exercise and don't smoke. Prevention is key to any health reform strategy.

Obesity and Diabetes

If losing weight and getting more exercise were easy, then chronic diseases, like diabetes, wouldn't be as much of a problem. Those lifestyle changes are notoriously difficult. But there's a glimmer of hope, which, if nurtured, could translate over the next decade to billions of dollars in savings to the health care system. Not to mention millions of lives improved or saved.

Rates of Type 2 diabetes -- the kind once called adult onset diabetes until it began afflicting people at younger and younger ages -- threaten to overwhelm the health care delivery system. Some 26 million people have diabetes, another 7 million have it but don't know it and the numbers are increasing at the rate of about 2 million new cases a year, the American Diabetes Association says. The cost of diagnosed diabetes is $174 billion a year. And diabetes is strongly linked to overweight, lack of exercise and poor dietary habits.

What may send our health care system over an economic cliff is the 79 million Americans with prediabetes, a disease precursor in which blood sugar levels are higher than normal but not as high as in diabetes. These millions now are poised to slip into diabetes -- a chronic illness that can result in amputated limbs, blindness or kidney failure or lead to heart attacks, strokes and early death. But they're still at a point now where, with help and hard work, they can avoid the disease.

Proof That What's Hard Is Not Impossible

In 2002, the federally funded Diabetes Prevention Project blew away assumptions about diabetes prevention. With moderate exercise (2.5 hours a week), modest weight loss (an average of 7 percent of body weight) and dietary changes to include more vegetables and fruit, prediabetics reduced their risk of getting the disease by 58 percent. More impressive, this study, with its 3,234 participants, showed that it is possible to actually get people to do what has long been thought nearly impossible: They can change lifestyle habits, lose weight and keep it off.

This was done with education about diet and exercise and the kind of one-on-one attention that few patients in the real world experience. A team of experts -- physicians, nurses, nutritionists and exercise coaches -- developed individual plans. Study participants kept food and exercise journals. They had calorie goals and learned how to read a food label. They met face to face with coaches and got check-up phone calls between meetings. The coaches became the equivalent of your nagging mother, calling to see what you ate today and if you took your daily walk. It worked.

Making it Work in the Real World

It's a huge leap, of course, from a dramatic finding in a federally funded study to the real world of yo-yo dieting and failed exercise resolutions. But to their credit, researchers did not stop: Their next step was figuring out how to translate their proven risk-reduction strategy and tactics and to make them work in the everyday. How do you get regular folks to adopt healthy changes?

The Centers for Disease Control and Prevention joined with the YMCA to try. They developed their effort based on the Diabetes Prevention Project, introduced it to Ys across the country and trained lifestyle coaches to work with prediabetics. The Y programs run in 21 states and the District of Columbia, though not yet in California. The CDC also tapped Emory University to provide training and technical assistance for national, state and community-based groups to help them develop local versions of this diabetes prevention program.

The results? Studies of those community-based programs in states including Indiana, Montana and Pennsylvania came close to and even, for some, exceeded the positive results of the federal study. A majority of patients in those studies lost 5 to 8 percent of their body weight -- and kept the weight off.

Other forms of individualized help can work, too. Two recent studies show that getting primary care physicians actively involved in helping their patients lose weight works. In one study, about 40 percent of patients actually were able to lose 10 or 11 pounds and keep it off for two years. Their doctors and health care providers offered either regular face-to-face "nagging," like the federal diabetes prevention study, or nudges via emails and telephone calls. In a second recent study, up to a third of participants in a weight loss program supported by lots of attention through their primary care physicians' practices lost 5 percent of their body weight.

The studies have shown that losing enough weight, while adding healthy foods and moderate exercise, is, indeed, possible. They've also shown that individuals need help -- either from their physician, or from a well-trained team within a community supported program. It's tough to make these changes and most people cannot do it alone. But research is showing us how to provide help.

A Billion Here, A Billion There, It Adds Up

So now, let's take it a step further. Again, researchers are ready with a modeled "what-if" scenario. What if people ages 60 to 64 who are at risk for diabetes were enrolled in a prevention program before they were 65 and eligible for Medicare? A recent report ran some numbers. A 16-week diabetes prevention program along the lines of the federally sponsored study and the YMCA-CDC partnerships would cost $590 million to enroll vulnerable pre-Medicare prediabetics -- roughly the cost of keeping 492 U.S. troops in Afghanistan for a year, say some nonprofit, independent military budget analysts. It's an important group because not only are they on the verge of developing a major disease, they are on the verge of making all of us pay for it through Medicare costs. Researchers project that treating that population could save Medicare $2.3 billion over the next 10 years and $9.3 billion of lifetime savings for the participants.

So what to make of all this information? Preventive care, especially in the case of diseases like diabetes and obesity, not only can make us healthier -- it can save us all huge sums. But as with all changes, it requires difficult commitments.

The policy-making debates that we're all hearing a lot of during the political season seem to rely excessively on speakers' "gut instinct," or little-explained beliefs; we're getting lots of grand political sketches with few details or price tags. But when it comes to health care, do we heed sound research, especially careful science that shows us not just what works in a test tube but also what can change our lives? Do we make relatively minuscule investments today to reap giant benefits tomorrow? I'm entertained by magical thinking -- if it stays at Disneyland. But when it comes to patients' care and the nation's health, let's stick to facts, research and science, especially when it tells us that good things can happen if we do.