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Editor—Narayan et al suggest that we use clinical and community based strategies to prevent type 2 diabetes.1 Over three years our small practice in Glasgow worked very hard to encourage healthy eating and exercise among our 2000 patients. We referred many patients to an exercise scheme, had a dietitian working in the practice, and organised health groups who met on a weekly basis where dietitian and doctor would weigh, encourage, motivate, and educate patients. Within a year almost half of my personal workload became this health promoting clinical input. In the end almost all of these patients required a continuous personal input to maintain their weight loss, regular exercise, or healthy eating, and it simply became unsustainable. Our energies were removed, and soon they all returned to their normal states.
I learnt a lot from that time. I listened to them in the health groups talking about the pressures and problems they faced. In the end I realised that it is not patients who don't understand but we doctors who don't. For how we behave, what we eat, what opportunities we have to exercise, are all shaped by what confronts us in our environment. If our environment is unhealthy then we are unhealthy. I also learnt that the poorer you are then the more you are adversely affected by your environment; the richer you are the more easily you can manipulate your environment to create a health advantage. This is called having lifestyle choices. The poor are simply stuck with their usual foul environment.
The prevention of obesity and type 2 diabetes is an environmental problem and not a medical one. Clinical and community based health promotion strategies would simply waste enormous amounts of limited resources and end up being demoralising for both medical workers and patients alike. A healthy population requires a healthy environment where all have the ability and opportunity to follow a healthy lifestyle.
Politicians have clung long and hard to the convenient concept of health promotion, which asserts that illness is primarily self inflicted. This is evil and redundant. We must strangle health promotion before it strangles us. It is not individuals who must change their behaviour, but politicians who must change their policies.
Editor—The trial by Tuomilehto et al showing the efficacy of diet and physical activity interventions for preventing type 2 diabetes is important and gives cause for optimism.1-1 It highlights the opportunities to prevent (or at least delay) a chronic, costly disease by using an individual level, lifestyle based programme. But how effective can such a clinical approach to diabetes prevention be outside the research trial situation?
The results of a similar dietary trial published concurrently were a little more sobering.1-2 Once the “intervention” period finished, body weight increased, and any residual gains from improved glucose tolerance applied only to the participants who were the most adherent to the programme. The parting comments about the need for a broader approach to diabetes prevention by Narayan et al in their editorial on the issue warrant amplification.1-3
The costs of medical treatment of diabetes are huge, but so are the costs of population screening and lifelong, intensive interventions for people at high risk. Our increasingly “obesogenic” environments are the driving forces for weight gain and diabetes. This is especially true for socioeconomic groups at the lower end of the range, who have fewer options for negotiating and manipulating their environments. The investment in sequencing the human genome, searching for magic bullet solutions, and testing clinical interventions is enormous.
The investment in sequencing the human genome, searching for long term, collaborative solutions, and testing environmental, policy, and community interventions is, at best, trivial. As with other behavioural epidemics—for example, smoking, injuries, or heart disease—we need to look beyond the “host” if the epidemic is to be contained.1-4 Until the obesogenic environments take centre stage in a broader public health approach,1-5 the prevalence of obesity and type 2 diabetes will continue to rise, especially in populations with a low income and in disadvantaged populations.