t’s time for John, a 41-year-old, to have his insulin. He has had insulin-treated type 2 diabetes for at least 17 years. Doctors have performed extensive laser treatment to his eyes because of diabetic damage to the retina. For some years now kidney function has been so impaired that John lives with the constant reality that sooner rather than later he will depend on a machine or somebody else’s kidney for life. Long ago he lost the ability to feel his feet properly. Without medication he is unable to enjoy what most 40-something-year-old men enjoy with their wives.

He has tried his best to care for his diabetes: four tablets every day to control his blood pressure—he has heard repeatedly that blood pressure control is crucial to preventing further eye, kidney, and nerve damage. Then there’s the matter f reducing the risk of stroke and heart attack: a large dose of cholesterol-lowering medication and aspirin to further reduce the risk of a catastrophic vascular event. Of course, there is the insulin. Four injections a day, every day—well, most days. If he is honest, there are many days when he skips his breakfast insulin. The mornings are so busy with getting the children ready for school and trying to get on the freeway before rush hour. Breakfast is often the last thought on his mind, and so is injecting insulin.

Sometimes he gets low, not just his blood glucose (sugar) reading, but his mood. And keeping all those appointments: his family doctor, the specialists. He never gets to the dietician or the diabetes nurse specialist. He wants to go, but he hates to go. Every time it’s the same. They are always very nice about it; nobody shouts at him. They are each just trying to do their job. But the messages scream—“We need to do better.”

So it should have come as no surprise when during a recent visit John chided me, “You know what? Diabetes is the last thing on my mind. I came today knowing the numbers would look bad and waiting for you to repeat the messages. I wanted to come and go as quickly as possible. My life is so much more than the numbers, the failing kidneys, the threat of a heart attack. I am married; I have a busy, demanding job and young children; and my wife and I are committed to ministry at our local church. Please, just give me the prescription and let me go.”

John and people like him (many millions across the globe have diabetes) don’t need nor want another article about what diabetes is. They live it. They understand the risk of complications. Many have them. Most people with diabetes know how to treat the disease and its complications. They have heard it all before. Nor do those who are at risk of diabetes (and there are many tens of millions throughout the world) want to be beaten up by the diet police, as well-intentioned and as correct as their mantra might be.

So, it is time for all of us to change our approach!

It’s Time for Compassion
As the song says, “Everyone needs compassion, . . . the kindness of a Saviour.”1

Diabetes is a progressive disorder that, despite an individual’s best efforts, becomes more challenging to treat over time. Not everybody is going to get complications; medical science offers treatments that can delay and even prevent complications in many people with diabetes. But even in the best of environments, the richest of countries, for most people diabetes doesn’t go away. No doubt weight loss is extremely effec-tive at treating type 2 diabetes, but for many this is a daily battle. For some, even preventing weight gain is a laudable outcome. Bariatric surgery (surgical treatment to cause and maintain weight loss) is an effective treatment for both obesity and diabetes. But access to such treatment is limited.

It’s Time to Stop Punishing
All of us, including health professionals, must stop punishing people who are at risk of diabetes with the stick of “lifestyle modification,” or even worse, the curse of fad diets, designed mostly to make money. Recently published was the outcome of a two-year study of lifestyle intervention in obese, well-educated, motivated volunteers.2 Those in the group of 811 participants were randomly assigned to four diets of varying proportions of protein, fat, and carbohydrates, along with group and individual counseling. Participants lost three to four kilograms of weight in two years, which is clinically meaningful and will delay the onset of diabetes, but the weight loss is still modest. Of particular importance, no differences between the groups were noted. The accompanying editorial made this observation:

“The inability of the volunteers to maintain their diets must give us pause. The study was led by seasoned investiators who were experienced in the performance of diet and drug trials. The participants were highly educated, enthusiastic, and carefully selected. They were offered 59 group and 3 individual training sessions over the course of 2 years. Nonetheless, their body-mass index (the weight in kilograms divided by the square of the height in meters) after 2 years averaged 31 to 32 [>30 kg/m2 is considered obese by the WHO] and was moving up again. . . . Evidently, individual treatment is powerless against an environment that offers to many high-calorie foods and labor-saving devices.”3

Lifestyle modification is crucial to improved health and well-being for all sorts of well-documented reasons. But if there is to be a reversal of the diabetes and the obesity epidemic, then personal choice alone is not going to cut it. It is time for all of us to promote whole community interventions, uniquely tailored to the local culture, to provide a macro-environment that promotes healthful lifestyle choices. Simply beating up on individuals while ignoring the broader arena in which people live, work, love, and worship will be of limited benefit and likely make those who practice psychological medicine busier as they deal with the consequent guilt.

It’s Time to Challenge Governments
The export and import of commodities that promote ill health must be stopped. In New Zealand the Meat Industry Association tells Pacific people who have a high prevalence of diabetes that lamb flaps (sheep bellies) are an ideal source of protein for those who can’t otherwise afford meat.4 If someone were to have meat as part of a diet, lamb flaps, which contain a high proportion of fat, would not be the food of choice, least of all for those struggling with obesity and diabetes. The export of lamb flaps has been likened to “dietary genocide.”5 Fiji has actually banned the importation of lamb flaps, and Papua New Guinea is considering interventions to limit and hopefully abolish the trade.

It’s Time to Change the Approach
Health-care professionals should design individualized treatments for those with diabetes, setting goals that are achievable, that will suit the particular circumstances a person finds themselves in, and are reviewed as circumstances change. There is good evidence that a treatment approach that tackles many risk factors can prevent or slow the progression of complications caused by diabetes. Attention to blood pressure, cholesterol, and blood glucose control is very important.

It is time for me and other health professionals to change our approach so that people with diabetes, such as John, do not dread their health-care professional visits.

It’s time for change.

Take-Home Messages
  • Diabetes is a progressive disorder that affects the day-to-day lives of millions of people.
  • Appropriate individualized treatment can prevent or significantly delay many of the complications of diabetes.
  • Weight loss helps to reduce the risk of developing type 2 diabetes and is likely to result in less treatment being required for the disorder.
  • The environment in many countries of the world is not conducive to weight loss. Without substantial changes to the macro-environment, efforts to lose weight are likely to result in modest benefits only.
For more information, go to www.papsda.co.nz.

1“Mighty to Save,” Ben Fielding and Reuben Morgan, 2006, Hillsong Publishing, www.hillsongmusic.com.
2F. M. Sacks et al., “Comparison of Weight-Loss Diets With Different Compositions of Fat, Protein, and Carbohydrates,” New England Journal of Medicine 360, No. 9 (Feb. 26, 2009): 859-873.
3M. B. Katan, “Weight-Loss Diets for the Prevention and Treatment of Obesity,” New England Journal of Medicine 360, No. 9 (Feb. 26, 2009): 923-925.
4“Lamb Flaps Ideal for Pacific People, Says NZ Meat Industry Assoc.,” March 24, 2009, Radio New Zealand International, www.nzi.com/pages/news.php?op=read&id=45520.
5“PNG Health Minister Calls for Tax on NZ Mutton Flaps,” March 24, 2009, Clearnet National News.

Warwick Bagg, M.B., B.CH., M.D., FRACP, is associate professor of medicine and associate dean (medical program), faculty of Medical Health Sciences, University of Auckland, New Zealand.  He is a member of the Papatoetoe community Seventh-Day Adventist Church.



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