A Call to Action: Intensive Lifestyle Intervention Against Diabesity

The U.S. health care system is being overwhelmed by an epidemic of obesity and type 2 diabetes, sometimes referred to as “diabesity.” This metabolic problem is not limited to hyperglycemia (high blood sugar), but in most cases includes lipid abnormalities (high cholesterol and triglycerides) and high blood pressure (BP). The major long-term complications of obesity-induced type 2 diabetes are renal failure; retinopathy, causing blindness; neuropathy, leading to chronic pain and foot problems that can require amputation; atherosclerosis (large vessel disease), causing myocardial infarction, heart failure, strokes; and peripheral vascular insufficiency (also a cause of amputations).

Treating these complications costs billions of dollars annually. In 2012, the American Diabetes Association (ADA) estimated the total annual U.S. cost of type 2 diabetes and its complications at $245 billion or about $671 million a day. Numerous clinical research studies have shown that intensive treatment to lower blood sugar, reduce BP, and decrease low-density lipoprotein cholesterol and triglycerides are powerfully effective in reducing the incidence of these devastating complications.

However, there are simply not enough endocrinologists to see and treat all the patients with this syndrome, let alone provide preventive care to patients who do not yet have diabetes but are at high risk. Wait times for new patients to see an endocrine-metabolism specialist in the private sector are often 40 days or more. The increasing numbers of new patients with diabesity are also overwhelming primary care providers. The current VA guidelines mandate new patients wait < 30 days for a medical subspecialty consultation appointment. Unfortunately, this is already impossible to meet, given the increasing numbers of diabetic patients and the limited capacity of the system.

The Diabesity Problem

Over the past 20 years, we have developed a whole new armamentarium of medications that either increase insulin secretion, increase sensitivity to insulin, or delay digestion and absorption of carbohydrates with the most recent addition being agents that promote urinary excretion of glucose. New long-acting and rapid-acting insulins allow us to simulate islet cell function with multiple daily injections or pump therapy. Nevertheless, good control of blood glucose still eludes far too many patients. Likewise, lipid-lowering drugs and combinations of antihypertensive agents with different modes of actions can reduce cholesterol and triglycerides and lower BP.

However, many patients are either unable or unwilling, as evidenced by the high rates of poor adherence. Moreover, many of the antidiabetic medications, including insulin, lead to weight gain, producing a vicious cycle requiring higher doses and additional therapies as time goes on. The medical model of treatment of diabesity is just not working or not working well enough.

Diabesity is not only a medical problem. It is also a lifestyle problem. The primary treatment recommended by the ADA and other national medical organizations for type 2 diabetes and patients at high risk for type 2 diabetes is a lifestyle intervention: Mainly weight loss by improved nutrition and a regimen of regular exercise. Despite clear evidence that these interventions, when implemented appropriately, are remarkably effective and knowledgeable medical care providers consistently recommend them to obese patients with diabetes, success in implementing them has been limited. As a result, we continue to attempt to control diabesity using the medical model of drug treatment.

Perhaps it is time to do something different. We know that exercise and weight loss are effective. What we have not figured out is how to get patients to exercise, eat healthful diets, and lose weight. We can estimate the costs of complications from our failure to treat diabesity successfully, and even the costs for treating the minority of patients who obtain some level of success by meeting goals for hemoglobin A_1c, lipid levels, and BP. These costs remain staggering.

What we have not examined are the comparative costs of large-scale, innovative programs to get patients to adhere to regimens of diet and exercise that will result in weight loss. Are such programs beyond our reach? I suggest they are not.

The private sector has voluntary pay-as-you-go programs, such as Weight Watchers, which achieve significant weight loss in a high percentage of participants. These programs work by a combination of motivational psychology and providing a user-friendly set of tools that enable clients to plan their nutritional programs and monitor the results, thus providing feedback that encourages success. Similarly, the Silver Sneakers program has had considerable success in getting older people to exercise regularly. A feature of these programs is group dynamics, in which people active in the program interact and encourage one another.

It is likely that a large-scale program that successfully gets patients to lose weight and exercise would be far less costly than treating diabesity and its complications. For private insurance companies, which largely avoid paying for long-term adverse outcomes for their current clients, such programs may fail the test of cost-benefit analysis. For the VA, where our patients tend to remain our patients “till death do us part,” programs of effective long-term prevention make perfect sense.