5 Things Patients Need for Diabetes Prevention

Payal Marathe

Senior Associate, Close Concerns

I was delighted to speak at the first World Congress on Targeting Metabesity, to represent the perspective of patients and the public. As a senior associate at Close Concerns, an organization focused on insights and information around diabetes and obesity, I have many thoughts on chronic disease prevention, and I was honored to be invited to share them. I was even more pleased to note that so many other presenters used similar vocabulary and touched on similar themes as those covered in my speech: the need to shift healthcare paradigms so that they’re proactive instead of reactive, a push for earlier diagnosis of complications with more diligent screening and monitoring, capitalizing on digital health platforms to engage people in their own health, recognizing the diversity of factors that determine health (everything from diet, to genetics, to behavior, to social and urban infrastructure, to loneliness).

The diabetes and obesity epidemics continue to rage. Globally, 425 million adults have type 2 diabetes today, and this number will grow to 629 million by 2045, according to the most recent IDF Atlas released on World Diabetes Day. These public health crises will not abate with treatment alone, unless we also focus on prevention. Over two days at the Metabesity congress, it was at least heartening to hear that so many people from different disciplines and areas of expertise are thinking about these same issues, and are thinking critically about prevention. Certainly, we’ll need a comprehensive, multidisciplinary approach to make prevention a success story.

In my remarks at the conference, during a session entitled “The Most Important Stakeholder: People,” I discussed five things that patients and would-be patients need to effectively prevent diabetes, obesity, and other chronic disease.

First, we must reduce stigma. Better yet, we would do away with it all together, but public health goals should of course be realistic, and completely eradicating stigma may take some time. Recent obesity statistics from the CDC and NHANES illustrate that stigma, and especially weight-based stigma, is a pervasive issue in society. In September, the CDC published maps of the US showing state-by-state obesity rates between 1985 and 2016. As expected, the maps get much darker as you approach modern day, with higher obesity prevalence everywhere. The CDC reported that West Virginia had the highest obesity rate nationwide in 2016 – 38%. A few weeks later, NHANES published findings from its 2015-2016 survey, reporting that national obesity prevalence among US adults was 40%. This averageis higher than the CDC’s highest statewide prevalence, so something doesn’t add up.

The CDC relied on self-report data to create its obesity maps, while NHANES pulls information from physical exam records, thus capturing a more accurate picture of the real obesity epidemic in the US. There is so much stigma in talking about obesity that people greatly underestimate it in self-report, and this lack of awareness is a hurdle in any prevention effort.

To overcome stigma, person-first language is key. In the diabetes community, people have largely swapped out the term “diabetic” for the phrase “person with diabetes” (though we still hear the word “compliance” far too often, which strikes a condescending tone and alienates the patient, when we should be talking about and motivating “patient engagement”). A similar transition needs to happen in obesity. People are not “obese,” as if this is the core piece of their identity. Rather, they are affected by obesity, a biological – and treatable – disease.

Second, to encourage health and wellness, the built environment needs to facilitate healthy behavior by making the healthy choice the easy choice. Dollar menus at fast food restaurants are understandably enticing – buy dinner for a couple bucks, feed your family for less than $10. People are motivated to save money (cash has value easily quantified, whereas the value of healthy behavior can feel abstract, and the negative consequences of poor health seem far in the future). To this end, there’s been some research to show that calorie labeling can backfire. These calorie counts can actually lead individuals to purchase higher-calorie meals, since it feels like you’re getting more bang for your buck. We should also appreciate people’s time as a resource. Some people lose hours each day in traffic, commuting to and from work, making it difficult to fit in the recommended daily physical activity.

Ideally, future built environments will make the healthy choice the easy choice. Healthy foods will be more accessible and affordable. Buildings will be constructed so that the stairs are front and center, making most people go out of their way to find an elevator or escalator. We can capitalize on the human tendency to go with what is default. When I arrive somewhere – and I’m not actually prioritizing healthy decisions in my minute-to-minute life, I’m primarily focused on getting where I need to go – I’m more likely to do what I see first, whether that’s the stairs or an escalator. Toronto and Copenhagen are strong examples of good built environment on a larger, urban scale, as these cities are designed with safe sidewalks, bike lanes, and parks so that physical activity is easy, and so that it’s built up as the social norm. The Toronto Waterfront Project has been an impressive revitalization effort that has a lot of potential going forward, and Copenhagen is one member of Cities Changing Diabetes, the program that just set a bold goal calling on cities to cut obesity rate by 25% by 2045 in order to keep type 2 diabetes prevalence below one in 10 (it’s currently one in 11, and will likely rise to one in nine if nothing is done about it).

Of course, this health-promoting urban and social infrastructure can’t be constructed by the healthcare sector alone – it’ll take collaboration from consumers, policymakers, and city planners as well, which once again highlights the importance of multidisciplinary approaches to prevention.

Third, conversations between patient and provider should cover what really matters, and decision support systems could help facilitate this. I’m not a patient with metabolic disease (though I do have a history of type 2 diabetes in my family), and honestly, I feel pretty awkward at many doctor’s appointments. These appointments are inconvenient to schedule, and once I’m there, it can feel like I’m taking up a busy person’s time even though my health appears to be in fine shape right now. As we shift toward prevention-focused, proactive healthcare, however, this is exactly what we want. We want people seeing their healthcare provider before the onset of disease, and we want individuals to be engaged in their own health and wellbeing so that they’re comfortable asking questions and getting answers.

As things stand, there’s a key difference between consumers and patients: Consumers feel ownership over the products they’re buying, and they want to make informed decisions. In contrast, most people today don’t feel that same level of ownership when it comes to their health, which is dispiriting, because developing a disease like diabetes or obesity will have a much larger impact on life than which new appliance you buy. Healthcare providers also need more support on this front. We hear often at diabetes conferences that providers are spending far too much of their time on prior authorizations, with an average of 15 minutes on each one, though this ranges up to 90 minutes. That’s a lot of precious time stolen away from the patient-consumer, which could otherwise be used to develop a trusting relationship, and to answer the questions that really matter. People don’t want to sit around waiting while their doctor stares at a computer, inputting information and reading charts, but decision support tools that help personalize treatment plans could pave the way here, freeing up some time.

Fourth, in a future healthcare system that is prevention-oriented, patients should have a say in how much risk they’re willing to take on. Many talks at the World Congress on Targeting Metabesity mentioned metformin, a now-generic drug used for six decades, and still the recommended first-line pharmacotherapy for type 2 diabetes. It has a strong safety and tolerability profile overall, and comes with convenient oral dosing. That said, metformin has not been approved with a prediabetes indication, despite demonstrated efficacy in preventing or delaying new-onset type 2 diabetes. Perhaps patients can decide if this is a pill they’d be willing to take in order to prevent diabetes, and we should empower people with all the safety and efficacy information they need (by putting it on drug labels) to make these choices when they’re engaged in their own health. It’s important to note that FDA has been making significant efforts to heed patient voices in the regulatory process, and this will hopefully be amplified in the years and decades ahead.

Fifth and finally, to make prevention a success story, we need to cultivate a sense of health citizenship – this, I believe, is the crux of patient-supportive, prevention-focused healthcare. Ultimately, people do need to take responsibility for their health and wellbeing, and for the health and wellbeing of people around them, but that starts with strong built environments and anti-stigma efforts. Hordes of people have embraced their role in protecting the environment – now and for future generations. It would really be something if all people began to feel this responsibility for health, just as fiercely as they feel responsibility to recycle and reduce their carbon footprint.


I’m sure these engaging, multidisciplinary conversations will continue at the second World Congress on Targeting Metabesity in 2018, and I look forward to noting what progress – large or small – has been made in prevention by then.