Challenging Dogma - Fall 2008

Friday, December 12, 2008

The Failure to Combat Type 2 Diabetes Mellitus – Jessica Small

More than eighteen million Americans are currently diagnosed with type 2 diabetes mellitus due to obesity, with the numbers growing every day (1). Despite increasing awareness of the dangers and hazards of being obese, no permanent and completely effective solutions have been created to decrease the incidence rates. There are three main areas in which public health is failing to combat obesity-induced diabetes mellitus. The first is that many of the approaches that exist focus on simply the physical aspects of being obese leading to the onset of diabetes, without considering other additional contributions to a person’s health. Secondly, many of the prevention programs in place are based on data collected from individuals who undergo routine checkups with their primary care physicians, excluding those who cannot afford healthcare. The third and final flaw is that they all insist on overall lifestyle changes, without considering the surrounding social contexts of obese individuals, and incorporating those aspects into their interventions. This paper will address each of these flaws, and then propose ideas for alternative interventions.

It’s More than Just the Physical Aspects of Obesity

Health officials currently focus on glucose levels as an indication of diabetes, without considering how stress, mental health, economic status, genetic fitness, or other health disorders can influence a person’s overall health. Currently, a person is considered to have prediabetes, or their blood glucose levels are elevated but they are not yet showing signs of intolerance to glucose, if their fasting glucose levels are between 95-125 mg/dL (2). It is at this point that increased daily exercise is recommended, and patients are usually referred to a nutritionist. However, this level is an arbitrary elevation point, and once levels have been decreased, a person may believe he or she is healthy again (3). They then may stop following a strict diet with exercise, and at this point, levels can become elevated again and may progress without any further treatment.

In general, public health officials assume that everyone considers their health to be a high priority, but this is not necessarily true. Individuals who have poor mental statuses may not benefit from simply increasing their daily exercise and healthy food intake, and may not even be concerned if the changes will help them. Those with high stress levels may not feel as if those two activities are as important as other aspects of their lives, and therefore will not follow instructions on how to improve their health. Furthering their careers or simply surviving is more important to many people than other issues such as healthcare.

There is also a number of confounding medical disorders that can lead to obesity or difficulty with weight gain, such as thyroid disease or even depression (4). In addition, there is evidence of genetic mutations leading to obesity, such as mutations in the peroxisome-proliferator–activated receptor transcription factor that plays a key role in adipocyte differentiation (5). There are also a few diseases currently recognized by the Centers for Disease Control as being contributors to obesity such as Bardet-Biedl syndrome and Prader-Willi syndrome, which are both genetic (6). None of these factors are considered by the current interventions that are in place; but they are all contributors to the incidence rates of obesity and diabetes. Presently, there is no model that has the ability to address other medical problems that can be tailored to communities or entire groups.

Money and Diet

As mentioned previously, many prediabetes and diabetes patients are referred to nutritionists. Meeting with a nutritionist may not be helpful if the individual is in poor economic standing. Recent research suggests that individuals in a low-income bracket (<$25,000 per year), or with a low level of formal education, are more than twice as likely to develop diabetes than individuals in higher income brackets or who have achieved high levels of education (7). Attaining a higher educational level might influence decision-making, and people with a higher income might have better access to health care, higher living standards, and other material benefits that have a positive impact on health. In addition, while a person may know and understand the correct foods to eat, it may not be beneficial for them to follow a strict diet, as it could compromise the quality of other aspects of their lives.

Additionally, individuals in low socioeconomic brackets may not be able to afford healthy foods as they tend to cost more than “junk” foods (8). Current food prices can be a deterrent to eating healthy alone. For example, within a two year period, the cost of foods with the highest number of calories but the lowest nutrient content per gram dropped 1.8 percent, while the cost of nutrient-rich, lower calorie foods likes fruits and vegetables rose 19.5 percent (8). When viewed in this perspective, it is possible to understand why so many obesity-related health campaigns are failing. In addition to the monetary issues, many people have multiple jobs or very hectic schedules, and have little time to even cook or prepare healthy meals. For them, eating something “on the go” that is not as healthy but is just as fulfilling may be their best and only option.

Flawed Identification Techniques

Currently, diagnosis of type 2 diabetes mellitus and candidates for primary prevention are identified at “opportunistic” encounters (1). In this manner, patients are referred during a visit with their primary care provider for a condition unrelated to diabetes or obesity. However, people with limited or no access to clinical care will be overlooked, and those with health insurance, access to higher-quality health care, and who are more likely to use the health care system will be preferentially identified.

As a result, the health interventions that have been created are tailored to those individuals in a higher socioeconomic bracket, and a mindset of maintaining a healthy lifestyle as they regularly visit a primary care physician. There is an entire subset of the general population that is being overlooked and these interventions will be unsuccessful in treating. As mentioned previously, not all individuals give their health a high priority, whereas the people being studied seem to. In addition, those with inadequate access to health care most likely have inadequate access to fresh, healthy food, as well. Therefore, the current interventions for changing a person’s diet and increasing exercise will not be applicable for these people.

Changes in Lifestyle

The third and perhaps most important reason for understanding why public health has been failing to decrease obesity is that none of the interventions take into consideration all of the surrounding social contexts for a person. In fact, many programs insist that people undergo overall lifestyle changes, without realizing that this is impossible for many individuals. Low socioeconomic status and poor mental health are large determinants of a person’s behavior (6). Those in poor economic standing are more likely to have less time to devote to healthy living practices, and less of a reason to bother trying. Many people below the poverty line simply want to survive even if they are unhealthy while doing so. Treatment for diabetes includes prescription drugs; and low socioeconomic status and poor mental health can contribute to less compliance and increasing health care costs (1).

None of the current interventions assess surrounding environmental influences on a person’s health, either. Many of the popular models, such as the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behavior, focus on individuals and their rational decision-making processes (9). All three assume that a person will rationally weigh the factors influencing their final decisions and that an intention will lead to an action. None of them take into account surrounding social contexts, such as the social norms or cultural beliefs of a group. For example, African American women tend to be more comfortable with their body image, regardless of their weight (10). If these women do not believe their health is a strong priority, they may have no further reason to lose weight, even if they are considered by all standards to be obese. In contrast, American Caucasian women tend to be more concerned with their body images (10), and may take more efforts to remain thin such as to exercise more often, and therefore decrease their chances of developing diabetes. It is important to note, however, that being thin does not necessarily mean a person is healthy. The models created to solve the issues of weight gain must take into account the mindset of groups of people and why they behave as they do, not individuals acting singly.

In addition, it has been found that there is a multitude of external factors contributing to obesity. For example, if you are middle-aged, an ethnic minority, unemployed or in an unskilled job, in a lower income bracket, are less educated, living with others, married and/or living in particular regions of the country you are an at increased risk of developing type 2 diabetes mellitus (11). None of the current models address all or even the majority of these issues at once. The limitations of these models, including their failure to account for differences in thought processes such as irrational thinking, and outside influences such as mental status, culture and socioeconomic standing, become evident as practitioners attempt to utilize their theories in public health practice. The failure to take into account all of the surrounding contributing factors has resulted in researchers developing solutions that cannot solve the issue of obesity in the broadest possible sense. All of the interventions have been streamlined to fit the belief that changing the behavior of people one at a time will decrease the overall trend of increasing unhealthy lifestyles in the general population.

What to Do When Taking a Look Beyond Physical Health

Currently, there is a number of confounding medical disorders that can lead to obesity or difficulty with weight gain, such as depression (4), that are not considered in present obesity-reducing campaigns. Because it is rare that interventions take into consideration all surrounding aspects of an individual’s health beside their body mass index and nutritional status, it would be ideal if individuals who are diagnosed with obesity-related type 2 diabetes undergo a screening process for additional common mental disorders than can cause or exacerbate the onset of diabetes. Studies suggest that stress, mood disorders, major depressive disorders, and anxiety disorders are significantly associated with obesity (12). In fact, it has even been found that patients seeking help are often disabled by their obesity, and therefore are more depressed than the general population (13).

Treatment should not just include medication for diabetes, but should also focus on the mental health impacts that can prevent improvement. For example, it has been found that consuming carbohydrates increases serotonin levels in the brain (14). Decreased amounts of the neurotransmitter, serotonin, has been implicated in depressive disorders and people can learn to overeat in order to increase serotonin levels and improve their moods (14). Therefore, the more depressed an individual is, the more likely he or she will overeat in order to relieve those feelings, and the greater the possibility of that person becoming obese or failing to lose weight.

In addition, according to the Stigma Theory, people will follow a self-fulfilling prophecy (9). In this case, those who are labeled as obese or overweight may never change their situation because they have been told all their lives that they are overweight. This is entirely counterproductive to public health interventions because if people believe they will never be able to live a healthy lifestyle, they may never try to change.

Treatments should include medication and nutritional counseling, along with mental health counseling so that people can understand that not only is change necessary, but it is also feasible.

Ideas to Consider for Problems with Money, Diet and Health

Individuals in low socioeconomic brackets may not be able to afford healthy foods, as they tend to cost more than “junk” foods (8). Access to fresh fruits and vegetables is simply not possible for many people, and it is this issue that must be addressed. It would be helpful if public health practitioners begin advocating for more personal gardening. A 130 day temperate growing season in a ten by ten meter plot can produce most of a four-person household’s total yearly vegetable needs, including much of the nutritional requirements for vitamins A, C, and B complex and iron (15). If individuals do not have enough of their own land to create these plots, public urban gardens are available in many communities. It might even be helpful to create a public garden on unused or idle land at health departments if it is obtainable.

In addition to the nutritional benefits of gardening, working with plants and being in the outdoors trigger both illness prevention and healing responses (15). Health professionals consistently use gardening materials to help patients of all ages induce relaxation and reduce stress (15), which may remove mental health barriers to increasing a person’s health status. Gardening is also an easy way to incorporate exercising into one’s daily routine. The act of working with plants and the ground can burn calories, increasing a person’s fitness. This may even help with weight loss for those who do not have adequate access to exercise equipment or who have a mostly sedentary lifestyle.

Gardening at an early age has already been shown to increase health awareness and teach children the best techniques for growing their own food. For example, Alice Waters implemented the Edible Schoolyard Project in Berkeley, CA, in which a garden was created within a schoolyard, and gardening and food production was incorporated into the school curriculum (16). In addition, a cooking class was created in order to teach students how to prepare healthy meals with the food items they had grown themselves (16). It may be beneficial to begin expanding this program throughout the country in order to introduce a forum that will instruct children how to not only cook their own food, but provide them with techniques for efficient growing practices, as well.

For those individuals who are wheelchair bound or who cannot garden on the ground, new products have been created to allow them access to gardening. Inventions such as the Table Top Garden Bed allow for gardening at the height of sitting in a chair and can be hand built out of excess wood instead of purchased (17).

In order to help this intervention gain momentum, models such as the Diffusions of Innovations Theory would be of practical use and should be kept in mind. According to this theory, one must consider an entire population and how it responds over time (9). Any behavior change will start off slowly and then gradually be picked up by others (9). Once an individual begins gardening, others in their community will slowly begin to see how easy it is and the benefits of its use. Hopefully, over time, entire communities will begin to participate, which may even promote community cohesion. Increased access to public gardens that can be created on empty lots may speed up the diffusion process.

Interventions Considering Surrounding Social Contexts

The third flaw of public health that the interventions do not take into consideration is the surrounding social contexts that can lead to obesity. As previously mentioned, if you are middle-aged, an ethnic minority, unemployed or in an unskilled job, in a lower income bracket, are less educated, living with others, married and/or living in particular regions of the country you are an at increased risk of developing type 2 diabetes mellitus (11). The limitations of these models include their failure to account for differences in thought processes such as irrational thinking, and outside influences such as mental status, culture and socioeconomic standing.

It may be practical to start educating community leaders on the adverse health effects related to diabetes and obesity in compliance with the Social Network Theory. This theory states that individuals base their behavior on the behavior of those around them (9). Community leaders are generally in contact with many people on a regular basis and have a large influence on individuals (18). They would be ideal people to act as a good resource to begin to change the way people perceive themselves in the context of their families and cultures. Training programs for these leaders could be implemented in order to teach them practical skills to pass on to their communities about how to eat nutritionally and live healthy lifestyles in the easiest and best way possible.

It is also important to stop emphasizing an overall lifestyle change for people whom that would be entirely unrealistic. The emphases should be placed more on making small changes to slowly try to improve overall health. Suggestions such as taking walks during lunch breaks or bringing healthy snacks to work are more feasible than instructing a low socioeconomic status individual to start going to the gym and to start eating healthy at every meal. One important suggestion could be to start buying canned fruits and vegetables if it is too costly to buy fresh, perishable fresh items. They are less expensive because they last longer and generally contain comparable nutritional values (19). In addition, many of these items are merely “open and serve” so they take very little time to prepare (19).

It is also important to note that the diagnosis of type 2 diabetes mellitus and candidates for primary prevention are identified at “opportunistic” encounters (1). It may be more practical to have schools begin implementing screenings for diabetes similar to those of the scoliosis screenings that are currently in place.

Generally, screening in populations is appropriate when seven conditions are met: 1) the disease represents an important health problem that imposes a significant burden on the population; 2) the natural history of the disease is understood; 3) there is a recognizable preclinical (asymptomatic) stage during which the disease can be diagnosed; 4) tests are available that can detect the preclinical stage of the disease, and the tests are reliable; 5) treatment after early detection is beneficial compared to those obtained when treatment is delayed; 6) the costs of case finding and treatment are reasonable, and facilities and resources are available to treat newly diagnosed cases; and 7) screening will be a systematic ongoing process and not an isolated one-time effort (20).

When considering type 2 diabetes mellitus, conditions one through four have been met, but five through seven have not been met yet because no clinical trials have been performed in order to determine the effectiveness of screening in decreasing mortality rates (20). Implementing screenings in schools would be beneficial because in this manner, all children have an equal opportunity of being diagnosed and receiving treatment, and not just those that received regular medical care.

Concluding Thoughts

The current public health approaches to combating type 2 diabetes mellitus by decreasing the incidence rates of obesity is a method that has been proven effective. However, the present methods are not practical and are not generalizable to the entire population. Far too often the interventions that are created are tailored to individuals with health care and adequate access to healthy food. Most of the solutions do not take into consideration people in lower socioeconomic brackets who simply do not have the time and resources, which factors into all aspects of a person’s life. Obesity is more than just a physical problem, there are flaws in the current identification techniques, and lifestyle changes are not always a realistic suggestion. Extenuating factors such as genetic disorders, mental health disorders, and other health issues are not always taken into account. In addition, none of the interventions consider the surrounding environmental influences on a person that could lead them to become obese such as cultural beliefs and family upbringing.

Public health needs to start looking at diabetes and obesity in a much broader sense, and incorporating as many other aspects of people’s lives as possible. The new models need to address culture, other health issues, poverty, low education and many other surrounding contexts that people are influenced by. They also need to take into account that not everyone has the ability to change their lifestyles, and may not have access to the best food all the time. In addition, they need to stop assuming that people will make rational decisions when it comes to their health, because people, by nature, tend to be irrational.


Journal Articles:

1. Narayan K, Jack L, & Laine C. (Eds.). (2004). Primary Prevention of Type 2 Diabetes Mellitus by Lifestyle Intervention: Implications for Health Policy. Annals of Internal Medicine. 140 (11):951-957.

5. Ristow M, Müller-Wieland D, Pfeiffer A, Krone W, & Kahn C. (1998). Obesity

Associated with a Mutation in a Genetic Regulator of Adipocyte Differentiation. New

England Journal of Medicine. 339:953-959.

7. Beckles G, & Thompson-Reid P. (2002). Socioeconomic Status of Women With

Diabetes—United States, 2000. JAMA , 51:147-159.

10. Huber JR. (1995). Cross-Cultural Examination of Women's Body Image Perception.

North American Society of Adlerian Psychology. 143-150.

12. Scott K, McGee M, & Wells JO (2003). Obesity and mental disorders in the adult

general population. Journal of Psychosomatic Research , 64 (1):97-105.

13. Fitzgibbon M, Stolley M, & Kirschenbaum D. (1993). Obese people who seek

treatment have different characteristics than those who do not seek treatment.

Health Psychology 12:342-345.

14. Wurtman RJ & Wurtman JJ (1995). Brain serotonin, carbohydrate-craving, obesity

and depression. Obesity Research , 3 (4):477-480.


2. Clark ME (2005). Primary Prevention of Type 2 Diabetes Mellitus: Role of Primary Care Providers. Retrieved 11 1, 2008, from WebMD:

3. American Diabetes Association. (n.d.). Pre-Diabetes. Retrieved November 11, 2008, from American Diabetes Association:

4. Maas D. (2007, January). Thyroid Disease Can Cause Fatigue, Weight Gain and More. Retrieved November 1, 2008, from Medical College of Wisconsin:

6. Department of Health and Human Services. (2008, May 21). Overweight and

Obesity: An Overview. Retrieved November 11, 2008, from Centers for Disease

Control and Prevention:

17. Blewden R. (2006, October 20). Neighbourgardens Table Top Garden Bed (TTGB).

Retrieved December 3, 2008, from Urban Agriculture Notes:

19. Kurtzweil P. (1999, May). Fruits and Vegetables: Eating Your Way to 5 A Day.

Retrieved December 6, 2008, from U.S. Food and Drug Administration:

Newspaper Articles:

8. Parker-Pope T. (2008, November 4). Money Is Tight, and Junk Food Beckons. The

New York Times. p. D6.

16. Edible Schoolyard. (2006). The Edible Schoolyard. Retrieved December 3, 2008,



9. Edberg M. (2007). Essentials of Health Behavior Social and Behavioral Theory in

Public Health. (R. Riegelman, Ed.) Sudbury, MA: Jones and Bartlett Publishers.

11. Sobal J. (2002). Social and Cultural Influences on Obesity. In P. Björntorp (Ed.),

International Textbook of Obesity (pp. 305-322). John Wiley & Sons, Ltd.


15. Bellows A, Brown K, & Smit J. (2002). Health Benefits of Urban Agriculture.

Community Food Security Coalition. 1-2.

18. Leonard A, Mane P & Rutenberg N. (2001). Evidence for the Importance of

Community Involvement: Implications for Initiatives to Prevent Mother-to-Child

Transmission of HIV. The International Center for Research on Women. New York:

The Population Council.

20. American Diabetes Association, Inc. (2002). Position Statement: Screening for

Diabetes. Diabetes Care , 21:21-24.

Labels: ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home