Tag Archives: Diabetes Prevention Program

The Streetlight Effect on Chronic Disease Prevention

 Once upon a time scientific thinking was a virtue…

But science as currently conceived  can also be like the tale of drunkard’s search also called the streetlight effect.

“Researchers tend to look for answers where the looking is good, rather than where the answers are likely to be hiding. (David H. Freedman, 2010)”

 Clearly it is not just science that can get stuck, but society as a whole, as the gap between scientific pursuits and their impact on societal progress  widens.  Could it be that as the gap between the rich and poor increases, so does the gap between what scientists are working on and what is truly beneficial for the common person?

The Streetlight Effect on Science

We have been ingrained with the virtues of science over the past few hundred years to the extent that many believe it can even supplant religion as the ultimate venue for seeking truth.

However, in spite of its many achievements, it’s becoming clear that science too is often like the emperor without clothing when practiced within our current economic framework.  In this framework, most scientists require funding in order to sustain themselves and their research.  Thus if the sources of funding are constrained by the wealth gap, and the motivation for research is to develop profitable products (i.e. marketable drugs and marketable behavioral interventions), we end up with a streetlight effect upon scientists that can limit the scope of the solutions they find (i.e. profitable solutions vs better but unprofitable solutions) .

Profitable vs Unprofitable Solutions to Problems

You may ask, “How can an unprofitable solution be good?”  It is all a matter of perspective.  For example, if I design a drug that a person with Alzheimer’s can take for life to reduce symptoms, I have a very profitable business.  I can patent the drug and people have to buy it from me.  There are barriers to keep people from getting the drug elsewhere or making it themselves at home.  However, if I work very hard to invent a behavioral intervention (i.e.  a lifestyle or multimodal stategy or perhaps a cognitively stimulating music / dance program) that completely prevents Alzheimer’s, and people can learn it on their own at home, I will be destined for the poor house.  Sure it is a better solution, but who in their right mind will work on it?  Who will spend good money on clinical trials and marketing for a superior but unprofitable product?

This is a huge dilemma for our society!

Unprofitable solutions are often the best for society as a whole but scientists may never seek them because of the streetlight effect.

Consider that the cost for the multi-center Diabetes Prevention Program (DPP) clinical trials has been estimated at $200 million over 10 years. This study showed that lifestyle intervention in the form of a 1 year program  consisting of 26 weekly sessions (20 sessions within the first 6 months and 6 sessions in the following 6 months) covering nutrition, weight loss, physical fitness and behavior modification was more effective than the drug Metformin, or the standard of care, for preventing pre-diabetics from becoming diabetics within 10 years.

Although it would seem that the results speak for themselves with 58% reduction in the incidence of diabetes ( up to 70% reduction for people over 60),  the justification for the DPP intervention comes not from the dramatic improvement in quality of life of the participants, but rather from demonstrated fact that insurers paying for the DPP can save on costs given the expenses associated with diabetes.

The effort to introduce prevention efforts for diabetes has been a very expensive 20 year battle that is still on going.  So where does that leave the future of prevention efforts for other chronic diseases such as heart disease, cancer, lower respiratory diseases, stroke, and Alzheimer’s?

Chronic Disease Prevention

Most people already accept that our economic system and it’s search for profitable solutions will result in the creation of environments where chronic diseases that could have been easily prevented flourish.  In this framework, things that exist in abundance become worthless. For example the air that we breathe is vital for healthy living but as of yet has little economic worth because of its abundance.

In the YouTube video, “Pay for the Air you Breathe,” the advertising agency Leavingstone in Tbilisi, Georgia  delivered the following message:  “If  we don’t care about the air we breathe, sooner or later we’ll have to pay for it.” 

What can we do to speed up the process of adopting prevention strategies as the gold standard for world health?

One thing seems certain,  we cannot afford to keep waiting for the scientific process trapped by the streetlight effect and  enormous costs / delays of RCT trials  to provide definitive answers.  Clearly health science is at a disadvantage when risk factors such as possible carcinogens, pollutants, pesticides, household chemicals, food additives, sources of stress, electromagnetic field exposure and sedentary work policies can be introduced into our environment at a much higher rate than the many years of RCTs that are needed to show definitive cause and effect.

These are some of our options:

  1. Become your own health detective.
  2. Become an expert on your own individual health.
  3. Find ways to unite with chronic disease prevention and health promotion advocates worldwide.
  4. Find ways to unite with world-wide economic change advocates.
  5. Vote for people who understand the importance of the above perspective for the future of world health.

As a health detective you will learn to monitor your health and environment more closely to detect symptoms earlier and effect environmental and lifestyle changes needed to correct problems before medical intervention becomes necessary.  The key strategy is development of personal agency (the ability to initiate actions that improve ones personal outcomes).

As an expert on your own individual health your doctor becomes your ally rather than your savior.  You are in a better position to keep yourself healthy than the doctor.  Of course the doctor is an essential part of restoring health if you are sick, but you must be the driver of your health.

There is strength in numbers and we must find more ways to unite with the specific goal of chronic disease prevention and health promotion at the community, national and world level.  The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) is a good place to begin the search for group involvement but must be greatly expanded upon in the years to come.  There are many groups already promoting multimodal chronic disease prevention strategies such as Sharp Again Naturally,  NEWSTART, AARP Global Council on Brain Health, etc.

Finally the elephant in the room must be addressed.  Human beings created our economic system and human beings can improve it. Sure it has been forged through suffering, sweat, tears and sacrifice throughout history largely through social structures based upon predatory-prey type relationships. But personal agency is our greatest asset and we must prevent our predatory-prey instincts from destroying the world and ourselves in the process.   Wealth inequality, slavery in the form of monetized debt and a profit driven economy that turns human beings into commodities are the greatest drivers of the world’s health problems.  The world needs a new vision of the future that includes health as the cornerstone.

Let’s begin building that vision.

Health’s Big Picture

Who defines health as “a state of complete physical, mental and social well-being?” Photo by svklimkin on morguefile.com

The World Health Organization’s (WHO) definition of health has not changed since 1948 when the organization was first created.  The organization demonstrated a futuristic vision by defining health as follows:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

The beauty of this definition is that it captures the holistic human being as composed of body, mind and spirit, where the spirit is accurately reflected by the social dimension of being.  The WHO definition of health was (and is) futuristic because our health system is traditionally based on the biomedical model which views health much more narrowly as simply the absence of disease or infirmity.  In the old perspective an unhealthy person is viewed as a broken machine that needs to be fixed, and the physician is viewed simply as a mechanic.  The mechanic is concerned with how to fix (i.e. cure) the problem rather than worrying much about how it could be prevented.

In the old biomedical model of health individual behavior,  social structures, culture and environment are assumed to be fixed and the only thing amenable to change is the individual’s biology and biochemistry.  An extreme example of this form of health care is the Army doctor who treats combat casualties.  It is assumed that combat is an essential aspect of the world and therefore preventing war is not perceived as an important goal of the health care system.

In 1977 George Engel’s biopsychosocial (BPS) model of health began ousting the strongly entrenched biomedical model of health and disease.   This model promotes WHO’s definition of health and holds the health care team responsible for evaluating the social, and environmental, psychological and physical causes of disease or infirmity.  However, as a society we have a long way to go before the BPS model and WHO’s definition of health can reach its full potential.

The Biopsychosocial Model of Health

If we work with the BPS model we can find root causes of illness and disease that are not simply limited to biology.  For example, in the US up to 80% of chronic diseases such as diabetes, heart disease and stroke are preventable with lifestyle, behavior and environmental modification strategies.  Because the biomedical model is failing us when it comes to chronic diseases, our government is finally coming around to implementing the BPS approach to health care.

In March of 2016 the Diabetes Prevention Program (DPP) became the first prevention service model ever to become certified for expansion by the Centers for Medicare & Medicaid Services (CMS) Innovation Center.  On January 1, 2018 the DPP is scheduled to begin benefiting more medicare beneficiaries.  The DPP consists of a coached 1 year program that helps people with pre-diabetes cut their risk of developing diabetes by 58% over a 5 year period through modest weight loss coupled with physical activity of 150 minutes per week.

This monumental transition from treatment of diabetes to prevention of diabetes has taken over 25 years of accumulated research that can be traced at least as far back as the 6-year Malmö feasibility study in Sweden that was published in 1991.   Twenty five years later, and following the Diabetes Prevention Programs multicenter clinical research study published in 2002, the US government has come to the conclusion that it can save money by helping people prevent chronic disease rather waiting for them to get sick and then having to pay for many years of treatment .  This positive transition in perspective may begin to fundamentally alter the future of health care in America and the world.

Is It Really all about Money?

In a poem by James Brown (pen name James J. Lachard) God says that what surprises him most about humankind is:

“That they lose their health to make money and then lose their money to restore their health.”

It never ceases to amaze me that of all earth’s species only humans are dependent on money in order to retain health!  No other animal needs it.   Does that make us smarter or in a way dumber than other animals?  Our brilliance seems to lie in harnessing the complexity of the brain to create more and more barriers in the path of success (and health) for a large portion of the population. Consider that in 2014 the number of US deaths from suicide totalled 42,773 (ranked number 10 overall) and that suicide was the second highest cause of death for ages 10-34.  These statistics bear down directly on the social aspect of health in the biopsychosocial model.

Unfortunately for man (and woman) it truly appears that our oversized cerebral cortex when compared to other mammals has been misappropriated to the task of obfuscation.  That is, our ‘smartness’ has been turned against us through centuries of manipulation by the few to control and harness the power of the many.  The sad result is thwarted social evolution even as technological knowledge and sophistication continues to increase.  This intelligent obfuscation  means that humans are often worse off than other animals with far less cognitive ability.

When seen in the proper context  it becomes evident that in the BPS model the biggest health challenges arise in the social sphere, because society has been structured to induce loss of health on many levels in order to promote the wealth of the few at the expense of the health of the many.

The Health of the Many Traded into Wealth for a Few

Any factor that reduces the spendable income of Americans ultimately takes a toll on health, especially when it affects food quality choices (i.e. organic vs non-organic, processed food vs fresh food), fitness choices (gym memberships and available time for fitness activities) or family time.  Thus excess income inequality, taxes, insurance costs, and interest payment costs  create a burden that decreases the holistic health of society.

Take for example how our society entraps college students today. The total student debt has been estimated at 1.3 trillion dollars and in 2016 two-thirds of graduate students owed an average of $35,000 each.  Debt needs to be called out as form of slavery!  We like to think of ourselves as a free country,  but yet we sell our children into the slavery of debt, and in fact the country as a whole is sold into slavery through the national debt.

The BPS model of health gives us a framework for making decisions to change social structures. such as a monetary system based on debt, that inhibit health as defined by WHO.

The Future of Health (Big Picture)

The earth and its biosphere can be viewed as a seed in the relatively lifeless environment of space.  Like a seed the earth contains in abundance all of the ingredients for life to develop to a certain extent, after which sustenance must be derived from outside of the seed.  In a like manner, the sun which powers our biosphere is a middle-aged yellow-dwarf star that is 4.6 billion years into its main sequence of life.   In as little as, 1 billion years we can expect the increase of solar output to begin causing serious challenges to life on earth.  This may seem like a long time but there are many technological barriers that must be overcome before life can expand from the earth-seed to other solar systems. In his 2015 State of the Union Address President Barrack Obama stated,

“I want Americans … Pushing out into the solar system not just to visit, but to stay.”

In order for our earth-seed to be successful, optimum health will be required of all of its human and non-human inhabitants.  By this I mean health according to the WHO definition: “…a state of complete physical, mental and social well-being.”  

From the biopsychosocial model we can see that this will require a complete overhaul of social structures throughout the world.  Social structures that are depleting and restricting our human potential must be replaced with new health-oriented structures such as debt-free societies.  Then the power of 7 billion human brains can truly be harnessed and applied to the future of the earth-seed.

Live long and prosper!

Live long and prosper! By NASA Astronaut, Terry W. Virts (nasa.gov, archived link.) [Public domain], via Wikimedia Commons