Dr. Jan Hux is an expert advisor with EvidenceNetwork.ca and the Chief Science Officer at the Canadian Diabetes Association. She has broad experience as a physician, researcher, educator and executive.
Journalist H.L. Mencken wrote that "for every complex problem there is a solution that is clear, simple and wrong." That observation aptly describes a prevailing attitude toward type 2 diabetes, which characterizes diabetes as a problem that could clearly be fixed if people would simply move more and eat less. Such a suggestion ignores much of what is known about the causes of the most prevalent and rapidly growing form of diabetes in Canada, and places an unwarranted burden of blame on those affected by it.
Type 2 diabetes is a complex problem with roots in genetics, the environment and individual behavioural choices. The role of genes is evident in the epidemiologic patterns of the disease. It is a condition that runs in families and few individuals diagnosed with type 2 diabetes do not have at least one relative who is affected. It is also more prevalent in certain population groups, most notably First Nations.
For some of those who carry a potent genetic risk for diabetes, no amount of physical fitness or healthy eating will protect them from developing the disease.
A second, less appreciated contributor to the growing diabetes epidemic is the role of the environment, specifically factors such as the walkability of neighbourhoods, food security and local access to health-related facilities and services.
Recent research in Toronto has demonstrated that, all else being equal, men living in the least walkable parts of the city are 32 per cent more likely to develop diabetes than those living in the most walkable neighbourhoods. For recent immigrants to Canada (many from parts of the world where the genetic risk is higher), the effect is even more striking, with a risk 58 per cent higher in the least walkable neighbourhoods. Similar results were found in women, with risk increases of 24 per cent for long-term residents and 67 per cent for recent arrivals.
It is also true that for people who are at risk of developing diabetes, behavioural choices that promote obesity increase that risk. Improving the diet and physical activity level of persons at high risk has been shown to reduce the risk by nearly 60 per cent.
Studies documenting the impact of behavioural changes are noteworthy because small changes in weight – on average, a loss of only 5 to 10 per cent – has significant benefits. Such findings have been widely promoted by public health agencies and practitioners in an attempt to empower individuals to reduce their risk of developing diabetes. However, over-emphasizing the importance of weight reduction may have contributed to unbalanced messaging to the public around the causes of the disease. It's time to right the balance.
To simply blame individual behavioural choices as the root cause of the diabetes epidemic does a disservice to those with the disease by creating stigma (a stigma which can even spill over to those with type 1 diabetes, a disease that it is not linked to obesity).
But there is an even greater danger with a simplistic understanding of diabetes that focuses exclusively on individual choice – it diverts attention and resources from other approaches which may be more effective at addressing the diabetes epidemic.
It is projected that by the year 2020, one in three Canadians will have either diabetes or pre-diabetes, a statistic that crystalizes the need for more emphasis on prevention, and illustrates why individual interventions alone are unlikely to be enough.
We can turn to Finland for inspiration.
In the late 1960s, North Karelia, a province in Finland, was found to have the world's highest documented rate of cardiovascular death among middle-aged men. In response, provincial representatives signed a petition to the Finnish government for urgent assistance to reduce the high burden of disease. Within a year, a multi-stakeholder community-based approach engaged food retailers, the food products industry and even the agricultural sector where, for example, a drop in demand for high fat milk products was managed by supporting dairy farmers to become berry farmers.
What was the outcome?
Over the next three decades, death rates from heart disease fell by 80 per cent and significant reductions were also seen in rates of stroke and cancer. This comprehensive approach that sought to address the whole population had a remarkable impact.
Can this experience be reproduced in Canada? There will be a number of challenges, but perhaps the first step is to effectively confront the misconception that diabetes is exclusively the fault of those who eat too much and move too little.
Diabetes is a complicated problem and that simple response has delayed real action.