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.