tudiabetes.org

We spend a lot of time in this blog talking about diabetes, the technical breakthroughs that advance its treatment and how to motivate decidedly nontechnical behavior change.

Here’s a chance to look back at the dramatic story of the most amazing (so far) technical breakthrough in the treatment of diabetes: insulin.

Breakthrough: The Dramatic Story of the Discovery of Insulin is on exhibit at the New York Historical Society through January 31.

I read this post a few months ago and it has haunted me ever since.  In it, C.J. Baker vividly articulates the feelings of frustration and anger that many patients with diabetes often feel:

“My problem is this– I know the end results. I know the risks. I know what dialysis and amputation and everything entails. I know. I’ve seen. I’ve treated…I work in medicine and will start school this May to pursue the dream of being a physician. But I’m the worst patient…

“The problem is I JUST CAN’T BRING MYSELF TO TEST, BOLUS, AND DO WHAT IS RIGHT!! I don’t test, and have a long history of doing so. I hate being consumed by it 24/7. I hate needing to plan everything and manage everything on my own. There are very few ailments (chronic, even) that require the patient to do ALL THE WORK.

“I sadly find relief in a visit to the ED with admission. Why? Because I get a break from it all. I might feel a little crappy. But I get a break….

“I don’t want to tick anyone off, but mild to moderate cancer seems a better bet. Why??  … You know what’s going on… the doctor manages the problem at hand… remission exists and even if it returns, the patient still got a break… cancer pt’s are given some sort of “credit” by the public… diabetics are just “fat” … diabetics can “control” and “cope” with the problem… cancer patient’s don’t have some magical blood count number that they have to check every few hours and make sure it’s perfect… cancer pt’s have support by the medical community…   the list goes on and on… yeah, cancer kills… but in my opinion, in a far less cruel and mysterious “maybe gonna happen but it’s ALL UP TO YOU” kind of way…

“I’ve tried to do well. But amid it all, bad blood sugars still creep in and tick me off… I hate to test. I hardly bolus until I get thirsty. To do better just makes me feel worse in general. I need to take care of others and my job requires me to be physical at times (lifting patients). I can’t afford to “deal with the pseudo low until my body re-adjusts” type of feeling. That, and I hate that feeling.

“I’ve tried everything I know. I’ve tried keeping meds in weekly pill boxes to help me remember. I’ve tried a pink glucometer to make me excited and/or happy about testing. I’ve tried gold stars, log books, “kudos calendars” … you name it. But it only lasts a week or so. Then I’m back to my depressed opinion again. I’d rather ignore it.”

In no other chronic disease is so much of the burden of success directly related to patient actions. In other words, the doctor can do everything right, but unless the patient steps up to care for herself, the outcomes are not good.

As this patient illustrates, knowledge alone is not enough. She knows what she should do, but is understandably overwhelmed with all that good self-care entails.

She’s not alone. There are approximately 21 million people in the US with metabolic diseases that are similarly Overwhelmed.  For suggestions on how to reach them, read this.

Wouldn’t it be great if we all had something like a “check engine” light on a car? We could walk into the Dr’s office and they could quickly and accurately know what was wrong and how to treat us.

It’s not that far fetched of an idea. Scientists in Japan have developed “magic” BEANS (Bio Electro-mechanical Autonomous Nano Systems) that can be implanted into a body and light up in response to glucose levels. They’re still years away from being used in humans, but they present some interesting opportunities.

On one hand, they offer a quick and non-invasive way of monitoring glucose levels for diabetes patients. If you look at it another way, it could also be a nice way of getting patients to pay more attention to their health and remain adherent to treatment. After all, who wants to be exposed as not taking care of their own health?

For health care practitioners, it would not only offer a look at clinical status, but might provide some insight on how well the patient is going to adhere to any of their treatment recommendations. That kind of knowledge could go a long way towards guiding intervention and treatment approaches. Fortunately, we already have tools to help predict patient behavior in chronic conditions.

With insights like these available and clinical tools like BEANS coming in the near future, we’re quickly running out of excuses for the continued increase in lifestyle-related diseases.

I love peanut butter and jelly sandwiches.  Well, actually jam, but you get the picture. Even now that I am old enough to be making them for my own child, I still eat a PB&J at least once a week.

So when I saw the Candwich I thought it was a joke.  Really, what could be easier to make than a PB&J?

And do you really want a sandwich that’s shelf stable for a year?

It got me thinking,  how much is the popularity of processed foods related to our burgeoning obesity epidemic?

Convenient and cheap, processed foods are a godsend to the time starved and budget conscious, but a dirty little secret lies within.

Turns out, all calories are not created equal. Take a cheddar cheese sandwich on whole grain bread and compare it to Velveeta on Wonder bread.  Same number of calories, but the processed option has about a 10% additional caloric burden because it doesn’t require as much energy to digest.  So processed foods actually help you put on more weight than whole foods with the same calories.

It’s easy to recommend eating whole foods over processed ones, but the fact remains that eating whole foods is much easier when you aren’t trying to make ends meet.  To change that behavior, you’ve got some serious cultural, behavioral and economic hurdles to overcome.

As Elaine Livas, who runs the Project SHARE food pantry, explains, “A gallon of milk is $3-something. A bottle of orange soda is 89 cents,” she says. “Do the math.”

My colleague shared an editorial with me from the June 2010 issue of The Lancet. It really hit home for me based on some things that have happened this week. The editorial comments on the June issue of The Lancet which is a special, diabetes-themed issue. The author notes a “glaring absence” from the issue – there aren’t any lifestyle/behavioral interventions that focus on diabetes prevention or reversal.

So, getting back to my week…I had a brief conversation with a notable physician who has spent many years in research and practice. We were discussing MicroMass’ new behavioral study that sheds light on a “metabolic mindset.” My energy and excitement around our findings was quickly deflated by his commentary on how behavioral interventions don’t work, that there’s no proof that they lead to any sort of measurable and impactful health outcome. Huh? What did I study for 2 years in graduate school? And what have I been so passionate about in my work over the past ten years at MicroMass? Could it be foolery?

I glance over at my health behavior and theory textbook from grad school and reflect on its content. Is it all lies? Then quickly I’m mad because I realize that while the physician has a point, so do I. I have seen evidence that behavioral interventions work. But, is the rigor and volume of the evidence in behavioral intervention research just not enough? And potentially more problematic, does this physician’s viewpoint reflect a broader opinion of the medical community?

I come from a clinical background. I know the value of medicine and I have seen it in action. Science is amazing and the medical research discoveries over the past decade have been amazing. So, why don’t people embrace, advocate and fund behavioral intervention at the same level as medicine? Is it because as a society we ultimately blame “others” for their self-inflicted, lifestyle-related conditions? Yet in the same breath, we grumble about rising healthcare costs and suggest that a large contributor is people who make unhealthy choices.

Regardless, there are plenty of examples, especially in chronic diseases like diabetes, that lifestyle changes and medicine go hand in hand. Patients need both to be successful.

If we expect to make any real change in diabetes or obesity in America, we have to be honest with ourselves. And we can only hope that decision-makers at the policy level can be honest with themselves too.

We’ve talked a lot here about America’s issues with food and eating and hunger and obesity. We’ve even got our own research that promises to help people change the difficult behaviors that lead to metabolic diseases.

Now, here’s a film that illuminates the complementary issue of food waste. The amount we waste is staggering.

Jeremy Seifert’s mission is to change what America puts in the trash.

Which would you respond to?

“Your lab results indicate you are likely to develop type 2 diabetes.”

or

“Your lab results indicate you have an 80% likelihood of developing type2 diabetes in 5 years.”

I know I would react more strongly to the second message. The authority that the absoluteness of the percentage demonstrates coupled with the sense of urgency of the time frame would make me take notice – actually, it would put me on notice.

 That is exactly what may come about with Tethys Bioscience, Inc.’s new diabetes risk score (DRS) test called PreDx®. According to Tethys, PreDx DRS reclassifies a vast “at-risk” diabetes population (currently 57 million) into more clearly differentiated risk categories, and identifies those individuals at highest risk of developing diabetes within the next 5 years. PreDex DRS uses quantifying biomarkers suspected of playing roles in diabetes development. In other words, this is personalized medicine in practice. It is taking you personally (literally) by directly measuring your body to generate your diagnosis. You can read more about PreDex DRS in this Technology Review article.

Armed with this more direct measure and more quantified risk assessment, doctors can now deliver the diagnosis in a new and more compelling way. Not only can the diagnostic test be more personal, but the delivery of the diagnosis can as well. Behavioral science tells us that because of our various behavioral biases, how a diagnosis is delivered can impact how we receive and act on it. You can watch a CBS Interactive SmartPlanet video segment that focuses on the impact of the PreDx® DRS on the physician and patient.

…which brings me full circle to ask, “Which would you respond to?”…

Earlier this year, Microsoft sponsored the Imagine Cup, a yearly competition focused on building applications to make our planet a better place to live.  We’ve talked previously about innovative ways to monitor a Diabetes patient’s condition, but this year’s Imagine Cup winner focused on diagnosis, specifically in third world countries. To top that off, they’ve re-purposed your everyday Windows Mobile smart-phone to do it.

Mobilife, the winning team, has developed software that works by using the phone’s camera to videotape a patient’s retina. The software then ships off the images to a set of servers that examine them for any micro-vascular anomalies that would indicate Diabetes, Hypertension or even Sickle Cell Anemia.  Post-analysis, a text message is delivered to the remote doctor with any diagnosis information.  Watch the video below to learn more about how the software works.

From a mobile marketing standpoint, this is another reminder that we need to stay focused on the core business of meeting unmet needs, instead of just following the latest trend or fad.  Unique and innovative thinking is what makes a mark in the mobile world, and with the right strategies you shouldn’t have a problem pulling in more than $2 a day.

I was browsing my inbox last week when a headline caught my eye – Why Spouses of Dialysis Patients Get Kidney Disease Too. Huh? Yes, I know that blood relatives are often at increased risk of diabetes and hypertension – two conditions that are often precursors to kidney disease. But spouses?

Sure enough, a study from Taiwan in the May 2010 issue of the American Journal of Kidney Diseases demonstrated that the risk of developing kidney disease for spouses of patients on dialysis is just about as high as it is for blood relatives. When the researchers compared the spouses of dialysis patients to a control group, they found higher rates of smoking, and high blood pressure. They also found that diabetes is a significant risk factor among those spouses.

Guess I need to pick up some of my old health education textbooks and brush up on the socio-ecological model. This model recognizes the intertwined relationship between the individual and their environment.

When you think about behaviors like what we eat and whether we exercise – there are so many things that stand in the way of making healthy choices.

I know – I face them every day. I walk in the office in the morning and my internal voice tells me it’s okay to eat just three chocolate donut holes (it’s not a whole donut anyway). Then at three o’clock my chocolate radar resumes as I roam the office to give my body just a little energy to get through the afternoon. And don’t get me started about exercise. In my environment, just 20 feet down the hall, stands a convenient piece of work out equipment. Also in my environment, my husband gets out of bed at 6:30 every morning and goes for a 4-mile run.

My personal health behaviors aside – as a health educator focused on creating (often non-personal) health communications, it’s easy to get fixated on trying to impact those factors within a person that often stand in the way of healthier living. I often don’t think of impacting environmental factors such as policy and organizational changes. However, in marketing, there still is the opportunity to impact families, social networks, and communities.

Believe it or not, there is room for public health in marketing.

It usually goes something like this:

• Patient goes to see doctor for an ailment
• Doctor assesses patient
• Doctor writes patient a prescription
• Patient thanks doctor and leaves, prescription in hand
• Patient decides not to fill the prescription.

From then on, the doctor and patient are operating under conflicting assumptions—a great plot for a 70s sitcom, but bad news for better medical care.

Recent research looked at primary nonadherence, that is, patients failing to fill an initial prescription. Rates of nonadherence were highest in metabolic diseases such as diabetes (31%), hypertension (28.4%) and high cholesterol (28.2%).

If so many people are failing to fill their scripts, but the doctor assumes that they are taking the medication as prescribed, how can treatment progress effectively?

Doctors are only as good as the information they have.

Given the high rate of primary nonadherence, doctors should make the following direct question a standard part of follow up visits, “Did you fill the prescription for Drug X that I gave you?” People are less likely to lie in the face of a direct question.

Obviously that one question won’t solve the communication disconnects that plague doctors and patients, but it’s a start.

So don’t lie to your doctors.  Trust me, they’d rather hear the ugly truth.