Shared doctor visits may help diabetes self-care


New York |
Thu Oct 10, 2013 3:14pm EDT

New York (Reuters Health) – Diabetes patients who agreed to attend group medical appointments at a Veterans Administration hospital showed health improvements similar to what most diabetes drugs would achieve, according to U.S. researchers.

Getting type 2 diabetes patients to take care of themselves and manage their disease daily is a challenge for healthcare providers, but shared doctor visits could be a useful tool, the study team says.

One way that hasn’t worked that well is to “lecture them,” according to senior study author Dr. Jeffrey Kravetz of the VA Connecticut Health Care System.

“People learn from each other and it is easier to learn from people who are in the same boat,” Kravetz said, adding that it is often more meaningful for people with diabetes to hear from a peer who understands the condition.

Type 2 diabetes can cause serious complications if it is not controlled by a combination of medication, diet and exercise. Healthcare providers agree the best way to approach this chronic condition is to educate patients to take care of themselves, but it’s tough to get people to be better self-managers.

Kravetz, together with pharmacist Alexander B. Guirguis and a team that included a nurse who specializes in diabetes, a registered dietitian and a health psychologist, tried a different approach: shared medical appointments, in which groups of three to 10 patients met in a 90-minute session every six to 12 weeks for a year.

About one quarter of the 8,000 veterans who are seen in the Firm A clinic of the West Haven VA have diabetes, Kravetz and his team write in the American Journal of Medicine.

Around 300 of those patients have exceedingly high levels of a blood protein known as A1C that indicates how well blood sugar has been controlled over the preceding several months. A1C levels greater than 9 percent are considered problematic.

For the study, selected patients with A1C around 9 percent or more were invited to join a shared medical appointment for diabetes management. Before their first visit, the patients agreed to sharing their medical results with the group, and were sent “report cards” with their blood test results.

The 90-minute appointments combined education and consultations with the medical team with peer support and education. The emphasis, according to team leader Guirguis, was to try to make the sessions more “patient interactive as opposed to provider led.”

The team would review patients’ blood test results openly and encourage patients to talk about their challenges and successes. The sessions usually ended with a question and answer session and brief talk by the dietician.

Of the sixty patients who signed up, 40 attended at least two group visits, 19 attended three or more visits and 15 attended four shared medical appointments over the year. And by the study’s end, some patients saw their A1C levels drop by as much as 1 percent, a change Kravetz says is about what would be expected from medication.

For instance, patients with A1C averaging 10.75 percent at the beginning of the study who attended two group appointments dropped to an average A1C level of 9.51 percent. Patients with lower starting levels of A1C – around 9.5 percent – dropped to an average of around 8.5 percent after attending three meetings.

In contrast, a comparison group of patients who were invited to participate but did not follow through had A1C levels that were unchanged or rose about a quarter of a percent over the year.

While these results mean the patients are still within the type 2 diabetes range (an A1C of 6.5 percent and above is considered type 2 diabetes), Kravetz considers them “pretty comparable to some major therapies.” He noted that at most a diabetes drug reduces the A1C by up to 1 percent and these patients are doing better than medication alone.

The team found that patients often shared similar experiences and could talk about how they overcame some of their obstacles to better self care: “We are trying to get people to talk about their barriers rather than lecture to them,” he told Reuters Health.

The majority of the behavior changes were diet and medication related. Guirguis recalls one patient who strongly identified with another patient’s story about setting up his insulin next to the coffee maker.

Another benefit of this kind of peer support is that patients who are leery of going onto insulin can observe peers who “are living perfectly normal lives” while on the medication regime, he said.

Helen Altman Klein, professor emeritus at Wright State University in Ohio, who has conducted extensive studies of diabetes self management education programs, considers this study “small scale in terms of medical research, but filling a very important niche in the field of diabetes education particularly when it comes to trying to help deliver services inexpensively.

“VAs have limited resources and need to serve a lot of people,” she said. “Sometimes with a VA, it’s no small thing for some people to sign up and even make an appointment.”

The Connecticut VA is planning to continue the group appointment program, including expanding into a multisite study. The team is also experimenting with peer-to-peer telephone support, and enrolling patients for the next study, according to Guirguis.

SOURCE: bit.ly/1czY0Xg American Journal of Medicine, online September 26, 2013.

Innovative technologies to manage diabetes better

Many health care solutions today, increasingly, ride on the technology train.

The pills and syringes, devices are still there, sometimes, but now have the ability to do their task faster, better, with greater sophistication, and least intrusion. That’s the way medicine is heading, and certainly in diabetes care.

An expert sitting at the very cusp where healthcare and technology have begun to work together, Satish Kumar Garg, the editor-in-chief, Journal of Diabetes Technology Therapeutics, talks to The Hindu on emerging technologies in diabetes care. He was in Chennai to deliver the 22nd Dr. Mohan’s Diabetes Specialties Centre Gold Medal Oration.

Real problem

“The real problem today,” he begins, “when we manage patients with diabetes is hypoglycaemia or low blood sugar. If we can take that one hurdle away, we can manage diabetes better.”

How does one reduce hypoglycaemia? “One way is to come up with new insulins that will limit low blood sugar conditions. There are some of these insulins that have already been approved in India and Europe, but not yet in the U.S. These are more reliable; they limit hypoglycaemia; effectively control blood glucose; and even help patients shed weight.” But here’s how technology gets a play here. “We ask people to check blood sugars two, three times a day, but what do they do with this. Now, it is possible to have metres that can provide advisories to the patient,” he says.

The moment they check their sugar, this data will show up on the iPhone. The phone has already mapped out their dosage, and based on their blood glucose, the phone will advice them on how much insulin to take.

“Now, if you can check your blood glucose continuously, it will reinforce for patients their actions: what dosage to take, should they eat more or less. This helps improve care.”

When patients start taking the right amount of oral drugs/insulin, this will reduce their glucose excursions both on the high and low end, data has shown.

Insulin pumps

Insulin pumps, very popular in the United States, indicate another way in which technology has come to the aid of the patient. There are over half a million people in the U.S. using insulin pumps, and data clearly shows that those using these devices have better glycated haemoglobin (HbA1C) levels and lower hypoglycaemia. This is because insulin is sent in smaller doses, not a large dose as when one takes insulin shot.

Since it is smart to marry relevant technologies to take on complex tasks; that is precisely what is happening in diabetes research as well. The culmination of that would be, naturally, replacing the human pancreas (which produces insulin) with an artificial one. Work is already on for this.

Dr. Garg predicts that the truly artificial pancreas will be complete in five years.

The artificial pancreas is actually a combination of the insulin pump and sensor. The part that has been approved so far, does the task of keeping a watch on the blood glucose, and when it senses a drop, it immediately sends a message to the pump to suspend insulin supply. This way, patients can avoid episodes of hypoglycaemia. The second innovation is for the sensor to tell the pump to speed up when sugars are high, but this is yet to be approved.

The third innovation already being contemplated is to use predictive algorithms to prevent hypoglycaemia events before they occur. “When we inject insulin, there is a delay in onset of action, for about 30 to 40 minutes. The sensor will know your glucose trends, so if it reads your glucose level at 110 mg, and it can predict that if you don’t act in the next half-hour, you are going down to 60 mg, and drop to hypoglycaemia,” he explains.

Missing part

If these innovations are also approved, then the only part that will be missing is glucagon. Dr. Garg says. “Glucagon is a hormone secreted by the pancreas to increase blood sugar levels. The artificial pancreas cannot do this as yet, but it will be a matter of time, I guess.”

Just as is the norm, technology which starts out expensive, will become cost-effective eventually. “It will make things easier for the patient. Imagine if he can control everything with his mobile phone. But the issue now is whether we can put this data on the cloud.”

Flip side

The problem with putting all this information on the cloud is leaving all of it open to those who can hack into it. “If someone hacks into the cloud, and we do have some crazy people, then, he can hack into your pump and increase the insulin dosage.”

You Can Now Manage Diabetes With a Wearable, Artificial Pancreas

We’ve been relying on artificial insulin injections for diabetes management for over 30 years now—which is practically ancient in modern medicine terms. But now, the FDA (presumably pre-shutdown) has approved an artificial, wearable pancreas that may finally kick all those painful insulin injections to the curb.

Made by Minneapolis-based medical device company Medtronic, the palm-sized pancreas helper continuously reads the users glucose levels and lessens the flow of insulin as need be—just a like a real pancreas would—almost. The difference between the two is that the pump doesn’t increase the amount of insulin in the presence or raised blood sugar. And while both glucose monitoring devices and insulin pumps are both currently available to diabetics, there was no system that combined the two until now.

You Can Now Manage Diabetes With a Wearable, Artificial Pancreas

And more than just being easier to use, this combined system may actually do more to save a patient’s life. Because both the monitor and pump are connected, if the beeper-like device notices that the wearer’s blood sugar is becoming dangerously low, it will automatically shut itself off for up to tow hours in order to prevent a diabetic coma.

Of course, no new technology is perfect, and the artificial pancreas does have a false alarm rate of 33 percent, according to Medtronics. Even with that, though, this is still one of the more accurate sensors we have available and is almost certainly one of the best ways to manage diabetes that we have available to us today. Plus, this is a major advancement that could, on day, lead to the production of an in-body artificial pancreas that really does work just like the ones Mom used to make.

Medtronic will start selling the device over the next few weeks, and they already have their eyes set on the next model: a fully automated version that requires absolutely zero input from the wearers themselves. [Singularity Hub]

Overweight and healthy: the concept of metabolically healthy obesity …

Plus-Size-Woman-Lifting-Weight

Carrying too many pounds is a solid signal of current or future health problems. But not for everyone. Some people who are overweight or obese mange to escape the usual hazards, at least temporarily. This weight subgroup has even earned its own moniker—metabolically healthy obesity.

Health professionals define overweight as a body-mass index (BMI) between 25.0 and 29.9, and obesity as a BMI of 30 or higher. (BMI is a measure of weight that takes height into consideration. You can calculate your BMI here.)

Most people who are overweight or obese show potentially unhealthy changes in metabolism. These include high blood pressure or high cholesterol, which damage arteries in the heart and elsewhere. Another harmful metabolic change is resistance to the hormone insulin, which leads to high blood sugar. As a result, people who are overweight or obese are usually at high risk for having a heart attack or stroke, developing type 2 diabetes, or suffering from a host of other life-changing conditions.

But some people who are overweight or obese manage to avoid these changes and, at least metabolically, look like individuals with healthy weights. “Obesity isn’t a homogeneous condition,” says Dr. Frank Hu, professor of nutrition and epidemiology at the Harvard School of Public Health. “It appears that it doesn’t affect everyone in the same ways.”

Dr. Hu and three colleagues wrote a “Personal View” article in Lancet Diabetes and Endocrinology reviewing what is known about metabolically healthy obesity. They identified several characteristics of metabolically healthy obesity. These include a high BMI with

  • a waist size of no more than 40 inches for a man or 35 inches for a woman
  • normal blood pressure, cholesterol, and blood sugar
  • normal sensitivity to insulin
  • good physical fitness

BMI isn’t perfect

BMI is not a perfect measure of weight or obesity. It often identifies fit, muscular people as being overweight or obese. That’s because muscle is more dense than fat, and so weighs more. But muscle tissue burns blood sugar, a good thing, while fat tissue converts blood sugar into fat and stores it, a not-so-good thing.

“Further exploration of metabolically healthy obesity could help us fine-tune the implications of obesity,” says Dr. Hu. “It supports the idea that we shouldn’t use BMI as the sole yardstick for health, and must consider other factors.”

Genes certainly play a role in how a person’s body and metabolism respond to weight. Some people may be genetically protected from developing insulin resistance. Others are genetically programmed to store fat in the hips or thighs, which is less metabolically hazardous than storing fat around the abdomen.

The concept of metabolically healthy obesity could be used to help guide treatment. Currently, exercise and a healthy diet are the foundation for treating obesity. When those efforts aren’t enough, weight-loss surgery (bariatric surgery) is sometimes an option. Such surgery is appropriate for people with metabolically unhealthy obesity, the authors suggest, but for people with metabolically healthy obesity it might make more sense to intensify the lifestyle approach rather than have surgery. This idea, however, needs to be tested in clinical studies, says Dr Hu.

Don’t rest easy

Metabolically healthy obesity isn’t common. And it may not be permanent, warns Dr. Hu. Just because a person has metabolically healthy obesity at one point doesn’t it will stay that way. With aging, a slowdown in exercise, or other changes, metabolically healthy obesity can morph into its harmful counterpart.

It’s also important to keep in mind that obesity can harm more than just metabolism. Excess weight can damage knee and hip joints, lead to sleep apnea and respiratory problems, and contributes to the development of several cancers.

Bottom line? Obesity isn’t good, even if it’s the metabolically healthy kind.

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Big breakfast may be best for diabetes patients

(HealthDay)—A hearty breakfast that includes protein and fat may actually help people with type 2 diabetes better control both their hunger and their blood sugar levels.

Patients who ate a big breakfast for three months experienced lower (glucose) levels, and nearly one-third were able to reduce the amount of diabetic medication they took, according to an Israeli study that was scheduled for presentation Wednesday at the European Association for the Study of Diabetes annual meeting in Barcelona.

“The changes were very dramatic,” said Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City. “I’m impressed with these findings,” added Zonszein, who was not involved with the study. “We should see if they can be reproduced.”

The researchers based their new study on previous investigations that found that people who regularly eat breakfast tend to have a lower (BMI) than those who skip the meal. BMI is a measurement that takes into account height and weight. Breakfast eaters also enjoy lower and are able to use more efficiently.

The trial randomly assigned 59 people with to either a big or small breakfast group.

The big breakfast contained about one-third of the daily that the would have, while the small breakfast contained only 12.5 percent of their total daily energy intake. The big breakfast also contained a higher percentage of protein and fat.

Doctors found that after 13 weeks, blood sugar levels and blood pressure dropped dramatically in people who ate a big breakfast every day. Those who ate a big breakfast enjoyed blood sugar level reductions three times greater than those who ate a small breakfast, and reductions that were four times greater.


About one-third of the people eating a big breakfast ended up cutting back on the daily they needed to take. By comparison, about 17 percent of the small breakfast group had to increase their medication prescriptions during the course of the trial.

The people eating a big breakfast also found themselves less hungry later in the day.

“As the study progressed, we found that hunger scores increased significantly in the small breakfast group while satiety scores increased in the big breakfast group,” study co-author Dr. Hadas Rabinovitz, of the Hebrew University of Jerusalem, said in a news release from the association. “In addition, the big breakfast group reported a reduced urge to eat and a less preoccupation with food, while the small breakfast group had increased preoccupation with food and a greater urge to eat over time.”

Rabinovitz speculated that a big breakfast rich in protein causes suppression of ghrelin, which is known as the “hunger hormone.”

The protein in the also likely helped control the patients’ blood sugar levels, said Vandana Sheth, a certified diabetes instructor and registered dietitian in Los Angeles and a spokeswoman for the Academy of Nutrition and Dietetics.

“We know when you eat carbohydrates, they can elevate blood sugar within 15 minutes to an hour,” Sheth said. “Protein takes longer to convert into glucose, as long as three hours, and not all of it goes to glucose. Some of it is used to repair muscle, for example. So it’s not a direct effect—100 percent of the carbs you eat convert to glucose, while only a portion of protein you eat converts to glucose.”

Zonszein said he has concerns about the study. For example, he said both the size and the length of the trial were insufficient, and he questioned why so many participants left before its conclusion.

However, he said the results were impressive enough that he might try the dietary strategy out in his own practice.

“It’s a virtually benign manipulation of the meal pattern,” Zonszein said. “I want to give it to my nutritionist to see what she thinks, and we may end up using it with several of our patients.”

The data and conclusions of research presented at medical meetings should be viewed as preliminary until published in a peer-reviewed journal.

More information: For more information on a diabetic diet, visit the U.S. National Library of Medicine.

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It can also increase likelihood of high blood pressure and high cholesterol

  • Napping for more than 30 minutes at a time can raise the risk of diabetes, according to a new study
  • It can also increase likelihood of high blood pressure and high cholesterol

By
Pat Hagan

19:04 EST, 20 September 2013


|

19:14 EST, 20 September 2013

They were much favoured by Margaret Thatcher, Albert Einstein and Winston Churchill.

But while afternoon naps may revitalise tired brains, they can also increase the risk of diabetes, according to new research.

A study of more than 27,000 people in China – where taking a post-lunch snooze is very popular – shows napping for more than 30 minutes at a time can raise the chances of developing type two diabetes.

Researchers found men and women taking 40 winks were also more likely to have high blood pressure and raised cholesterol levels compared to those who stayed awake through the day.

Napping for more than 30 minutes at a time can raise the chances of developing type two diabetes, according to a new study

Napping for more than 30 minutes at a time can raise the chances of developing type two diabetes, according to a new study

The findings, published in the journal Sleep Medicine, are in contrast to those from other recent studies, which found daytime sleeps could boost brain power and slash the risk of heart attacks and strokes by more than a third.

The researchers said it’s the duration of the nap that counts. Those dozing for half an hour or more were more likely to have the early signs of diabetes than those who snoozed for less time or not at all.

In 2009, a planned UK National Siesta Day was cancelled when similar research from China found a 26 per cent increase in diabetes risk among those regularly getting their heads down in the afternoon.

Diabetes affects an estimated 2.5 million people in the UK. Around ten per cent of cases are due to type one, which is thought to be caused by a malfunctioning immune system and has nothing to do with diet.

Diabetes affects an estimated 2.5 million people in the UK. Above, a woman tests her blood sugar (file pic)

Diabetes affects an estimated 2.5 million people in the UK, with around ten per cent of cases due to a malfunctioning immune system. Above, a woman tests her blood sugar (file pic)

But the remaining 90 per cent are type two, closely linked to unhealthy diet and lifestyle.

The body loses its ability to make use of glucose, a type of sugar that is released when we eat food and turned into a source of energy for use by muscles.

As glucose levels rise, circulation starts to suffer and blood vessels in areas such as the heart, the legs and the eyes can be irreparably damaged.

In the latest study, researchers at the Huazhong University of Science and Technology in China studied 27,009 men and women aged 45 or over.

Former Prime Minister Margaret Thatcher was famously known for napping

Former Prime Minister Margaret Thatcher was famously known for napping

Almost 70 per cent of the volunteers said they regularly took a nap in the afternoon.

Researchers checked their health by carrying out a test called impaired fasting plasma glucose.

This measures whether sugar in the blood is too high and acts as an early warning sign that type two diabetes is setting in.

Researchers also looked to see which volunteers were in the early stages of the disease.

They found glucose readings were much higher among those who favoured a daytime sleep.

Forty per cent of them also had high blood pressure, compared to just 33 per cent of non-nappers, and 24 per cent had high cholesterol, versus 19 per cent.

One reason a siesta may be harmful is it simply means less exercise is being undertaken, the researchers said.

But it could also be that it disrupts the body’s internal clock and exposes organs to higher levels of the stress hormone cortisol.

In a report on their findings the researchers said: ‘Napping in the elderly can be beneficial for daytime functioning, as well as for mental health.

‘But there is accumulating evidence showing it may also be a risk factor for morbidity and mortality.’
Dr Matthew Hobbs, head of research for Diabetes UK, said there was no proof that napping actually caused diabetes.

He said: ‘The bottom line is that the best way to reduce your risk of type two diabetes is to maintain a healthy weight by eating a healthy, balanced diet and by being regularly physically active.’

The comments below have been moderated in advance.

My dad and grandfather took a nap every day. Neither one ever had health problems. This study sounds like it was staged.

Grace
,

tucson, United States,
21/9/2013 03:01

Where do you people get these study ideas? Is there anything you are not studying? If we believe all these studies we will find that everything we do is bad for us and everything we do not do is what is good for us. The egg is bad, no the egg is good, napping of all things being deadly is the last straw. How come sleeping at night doesn’t kill us too? Oh wait, we snore!

scottyusa
,

Windham, United States,
21/9/2013 03:00

What a load of cobblers if was good enough for Maggie,Albert and Winnie then it is good enough for me,i love my afternoon naps.I am retired and no i do not have diabetes,high blood pressure or high cholesterol but i do exercise a lot.

wolfy
,

warrington,
21/9/2013 02:59

Correlation does not equal causation. Likely,the people who take naps are less fit, less healthy and take naps because of these health issues.

Lisa
,

Melbourne,
21/9/2013 02:57

I think you’ll find you have ’cause’ and ‘effect ‘ the wrong way round here……

NHS Nightmare
,

Huddersfield, United Kingdom,
21/9/2013 02:49

nooooo….I like having a nap

texanscot2005
,

Htown,
21/9/2013 02:37

I guess that I am okay, as I have never taken a nap in my life. I can only sleep in a bed at night, however tired I might be.

rickyo
,

Charleston,
21/9/2013 02:35

Maybe they are already ill and need to nap because of this not the other way around.

Mrs Runner5k
,

Maryland,
21/9/2013 02:30

Or do people who have a nap are more likely to to have diabetes?

DanStlMo
,

ST Louis Missouri, United States,
21/9/2013 02:15

Does the nap cause the diseases, or do they nap because they already have early signs of the diseases?

PB
,

Atlanta,
21/9/2013 02:11

The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline.

UPDATE 1-Roche decides against selling diabetes device unit -sources


Thu Sep 19, 2013 10:46am EDT

By Soyoung Kim and Jessica Toonkel

NEW YORK, Sept 19 (Reuters) – Swiss drugmaker Roche Holding
AG has decided against trying to sell its blood glucose
meter business, according to two people familiar with the
matter.

At least one other large drugmaker, Bayer AG,
also scrapped plans to sell a diabetes device unit this year.

In the past few months, Roche was looking to sell the
business as the industry faced increased competition and lower
reimbursement rates from U.S. government healthcare programs,
people familiar with the matter told Reuters in May.
.

However, the reimbursement pressure on diabetes test
supplies lessened the chances of a competitive sales process,
leaving Roche little choice but to hold on to the business,
according to one of the people who spoke to Reuters this week.

The people wished to remain anonymous because they are not
permitted to speak to the media.

A Roche spokesperson said in an email that the company
remains committed to its Diabetes Care division.

Bayer, Germany’s biggest drugmaker, had attempted to sell
its blood glucose meter business for about $1.5 billion, only to
pull the plug on the sale early this year after failing to
attract sufficient interest.

The diabetes device market came under pressure earlier this
year after the U.S. Centers for Medicare Medicaid Services
moved to cut the reimbursement for diabetes test supplies by up
to 72 percent.

The change, which took effect in July, makes it more
difficult for companies to be profitable in this business.

Biomarker that can predict diabetes risk identified

Scientists have identified a biomarker that can predict diabetes risk up to 10 years before onset of the disease.

Researchers at the Vanderbilt Heart and Vascular Institute and Massachusetts General Hospital in US conducted a study of 188 individuals who developed type 2 diabetes

mellitus and 188 individuals without diabetes who were followed for 12 years.

“From the baseline blood samples, we identified a novel biomarker, 2-aminoadipic acid (2-AAA), that was higher in people who went on to develop diabetes than in those who did not,” said Thomas J Wang, director of the Division of Cardiology at Vanderbilt.

“That information was above and beyond knowing their blood sugar at baseline, knowing whether they were obese, or had other characteristics that put them at risk,” Wang said.

Individuals who had 2-AAA concentrations in the top quartile had up to a fourfold risk of developing diabetes during the 12-year follow-up period compared with people in the lowest quartile.

“The caveat with these new biomarkers is that they require further evaluation in other populations and further work to determine how this information might be used

clinically,” Wang said.

The researchers also conducted laboratory studies to understand why this biomarker is elevated so well in advance of the onset of diabetes.

They found that giving 2-AAA to mice alters the way they metabolise glucose. These molecules seem to influence the function of the pancreas, which is responsible for making insulin, the hormone that tells the body to take up blood sugar.

“2-AAA appears to be more than a passive marker. It actually seems to play a role in glucose metabolism,” Wang said.

“It is still a bit early to understand the biological implications of that role, but these experimental data are intriguing in that this molecule could be contributing in some manner to the development of the disease itself,” he added.

… contd.




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Does the process of diseasification hold any promise in obesity?

In a thoughtful, measured and well-reasoned blog post, Dr. Keith Ayoob recently discussed the AMA’s decision to classify obesity as a disease. As he concluded his post, Dr. Ayoob wrote: “I don’t care how obesity is categorized. I care about what’s being done about it … We need to stop talking about whether obesity is or is not a disease and start talking about preventing it altogether.” This got me thinking: does the process of diseasification hold any promise at all in obesity? And are there downsides to this approach that should cause us concern?

Diseasification is a funny and not entirely real word, but I didn’t make it up. Sure, if you look for it in an online dictionary, you won’t find it — but if you Google it, you’ll find over 6,000 hits. Most seem to focus on one of the most problematic aspects of diseasification: that of classifying all sorts of mental states and psychological issues as diseases, a tendency that has arguably contributed to our nation’s overreliance on pharmacology to ease the vicissitudes of daily living. But some of these Google hits refer to issues in prevention, including obesity. While I didn’t coin the term, I think its meaning is self-evident: labeling as a “disease” a condition that is typically not so construed. Clearly, the AMA’s action would fit under this intuitive definition.

Of course, this begs the question: what is a disease? A typical definition of disease provides guidance, if not absolute clarity: “any deviation from or interruption of the normal structure or function of any body part, organ or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology and prognosis may be known or unknown.”

In holding obesity up to this standard, its appropriateness could hinge on whether a body with a body mass index (BMI) greater than 30 would be considered a normal structure; this in turn depends on how we define normal. Ironically, if we refer to a standard statistical concept of outliers — usually, the most extreme 5 percent or so of a population — then the more widespread our so-called national obesity epidemic, the more “normal” obesity becomes. Currently, more than a third of the entire U.S. population is obese; in certain states and in some ethnic/racial groups, the proportion is closer to half. Clearly, these are not outliers.

But I think the annals of preventive medicine have demonstrated that diseasification has its place. Let us look at a reasonably successful story of diseasification: that of hypertension. Some readers might be surprised that I’m considering this diseasification: after all, isn’t hypertension clearly a disease? Well, no, it’s not. There are no symptoms, illnesses or dysfunctions related to hypertension per se. Hypertension refers to an elevated blood pressure, where elevated was established in a discretionary (though certainly not arbitrary) manner. Coincidentally, about a third of all Americans fit the definition of people with hypertension, so these are also not outliers in the traditional sense. But what we do know is that high blood pressure is a major, modifiable risk factor for things that are diseases — important ones, such cardiovascular diseases, of stroke and heart attack. Moreover, we know that pharmacological efforts to lower blood pressure below established cutpoints leads to a reduction in the risk of such diseases. So diseasifying hypertension has led to helpful treatments and to a reduction in disease outcomes.

Obesity, however, is a wholly different animal. First, while obesity has been shown to be a risk factor for certain diseases — indeed, many of the same diseases predicted by high blood pressure — its association with those diseases is neither so strong nor so direct as that with hypertension. Moreover, healthcare practitioners do not have the sorts of treatments in their toolkits to treat obesity that they do for high blood pressure, and even more significantly, there is no direct evidence that using treatments to lower BMI will in turn reduce the risk of the real diseases that are associated with obesity — the ones we really care about.

Thus, the presumed upsides of this new AMA-endorsed classification are hard to imagine. Given the lack of effective and proven therapies, what benefit do we seek? Prevention, as Dr. Ayoob indicated, is key — but our rapidly exploding national obesity prevalence isn’t caused by lack of adequate medical care; rather, it is due to wholesale changes in diet and lifestyle, largely promoted by corporate marketing, governmental policies, new technologies and changing norms of behavior. These are amenable (alas, not easily) to public health interventions and policy change, but not to increased doctor visits.

An open question is: if this relabeling of obesity has an impact on the stigmatization of the overweight, will it be for good or ill? On the good side, perhaps, is recognizing that it isn’t necessarily a sign of sloth or weakness of will, but something that may be beyond volitional control, much as classification as disease may have improved the situation for alcoholics or substance abusers. On the other side — do we really want to equate obesity with such things? I think we ought to heed lessons from the fat acceptance movement, and consider that the overweight seem to be the last social group that it is deemed acceptable to malign.

Certainly, there are many fat people comfortable in their own bodies; do we really want to say to them, “Sorry, it doesn’t matter what you think, you’re sick”? Not a necessary corollary of diseasification, I think, but a cause for concern.

Paul Marantz is associate dean, clinical research education and director, Center for Public Health Sciences, Albert Einstein College of Medicine. He blogs at The Doctor’s Tablet.

Diseasification of Obesity

 

Bathroom scale with faces instead of numbers

 

In a thoughtful, measured and well-reasoned blog post in these pages, Dr. Keith Ayoob recently discussed the AMA’s decision to classify obesity as a “disease.” As he concluded his post, Dr. Ayoob wrote: “I don’t care how obesity is categorized. I care about what’s being done about it…. We need to stop talking about whether obesity is or is not a disease and start talking about preventing it altogether.” This got me thinking: does the process of “diseasification” hold any promise at all in obesity? And are there downsides to this approach that should cause us concern?

“Diseasification” is a funny and not entirely real word, but I didn’t make it up. Sure, if you look for it in an online dictionary, you won’t find it—but if you Google it, you’ll find over 6,000 hits. Most seem to focus on one of the most problematic aspects of diseasification: that of classifying all sorts of mental states and psychological issues as diseases, a tendency that has arguably contributed to our nation’s overreliance on pharmacology to ease the vicissitudes of daily living. But some of these Google hits refer to issues in prevention, including obesity. While I didn’t coin the term, I think its meaning is self-evident: labeling as a “disease” a condition that is typically not so construed. Clearly, the AMA’s action would fit under this intuitive definition.

Of course, this begs the question: what is a “disease”? A typical definition of disease provides guidance, if not absolute clarity: “any deviation from or interruption of the normal structure or function of any body part, organ or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology and prognosis may be known or unknown.” In holding obesity up to this standard, its appropriateness could hinge on whether a body with a body mass index (BMI) greater than 30 would be considered a “normal structure”; this in turn depends on how we define “normal.” Ironically, if we refer to a standard statistical concept of outliers—usually, the most extreme 5 percent or so of a population—then the more widespread our so-called national obesity epidemic, the more “normal” obesity becomes. Currently, more than a third of the entire U.S. population is obese; in certain states and in some ethnic/racial groups, the proportion is closer to half. Clearly, these are not “outliers.”

But I think the annals of preventive medicine have demonstrated that diseasification has its place. Let us look at a reasonably successful story of diseasification: that of hypertension. Some readers might be surprised that I’m considering this “diseasification”: after all, isn’t hypertension clearly a disease? Well, no, it’s not. There are no symptoms, illnesses or dysfunctions related to hypertension per se. Hypertension refers to an elevated blood pressure, where “elevated” was established in a discretionary (though certainly not arbitrary) manner. Coincidentally, about a third of all Americans fit the definition of people with hypertension, so these are also not “outliers” in the traditional sense. But what we do know is that high blood pressure is a major, modifiable risk factor for things that are diseases—important ones, such cardiovascular diseases, of stroke and heart attack. Moreover, we know that pharmacological efforts to lower blood pressure below established cutpoints leads to a reduction in the risk of such diseases. So diseasifying hypertension has led to helpful treatments and to a reduction in disease outcomes.

Obesity, however, is a wholly different animal. First, while obesity has been shown to be a risk factor for certain diseases—indeed, many of the same diseases predicted by high blood pressure—its association with those diseases is neither so strong nor so direct as that with hypertension. Moreover, healthcare practitioners do not have the sorts of treatments in their toolkits to treat obesity that they do for high blood pressure, and even more significantly, there is no direct evidence that using treatments to lower BMI will in turn reduce the risk of the real diseases that are associated with obesity—the ones we really care about. Thus, the presumed “upsides” of this new AMA-endorsed classification are hard to imagine. Given the lack of effective and proven therapies, what benefit do we seek? Prevention, as Dr. Ayoob indicated, is key—but our rapidly exploding national obesity prevalence isn’t caused by lack of adequate medical care; rather, it is due to wholesale changes in diet and lifestyle, largely promoted by corporate marketing, governmental policies, new technologies and changing norms of behavior. These are amenable (alas, not easily) to public health interventions and policy change, but not to increased doctor visits.

An open question is: if this relabeling of obesity has an impact on the stigmatization of the overweight, will it be for good or ill? On the good side, perhaps, is recognizing that it isn’t necessarily a sign of sloth or weakness of will, but something that may be beyond volitional control, much as classification as disease may have improved the situation for alcoholics or substance abusers. On the other side—do we really want to equate obesity with such things? I think we ought to heed lessons from the fat acceptance movement, and consider that the overweight seem to be the last social group that it is deemed acceptable to malign. Certainly, there are many fat people comfortable in their own bodies; do we really want to say to them, “Sorry, it doesn’t matter what you think, you’re sick”? Not a necessary corollary of diseasification, I think, but a cause for concern.

Paul Marantz, M.D., M.P.H.