Physicians find it takes a village to help tackle diabetes

Public health officials and doctors turn to community groups, churches, schools and government officials to increase opportunities for people to exercise and eat right.

By Victoria Stagg Elliott, amednews staff. Feb. 11, 2002.

Frustrated by the stream of kids coming into his office obese and either already diabetic or on the verge, pediatrician John Menchaca, MD, of Fort Worth, Texas, met with the local school administration to try to convince them to increase opportunities for the young people to exercise.

His position was strengthened by data he helped the University of North Texas Health Science Center School of Public Health gather. The findings: Extremely high rates of diabetes risk factors among the Fort Worth students. The result: All children in kindergarten through fifth grade are now required to participate in physical education.

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But Dr. Menchaca did not stop there. Equally concerned about his patients' parents, he has also met with the community's large employers to lobby them to provide access to exercise facilities for their employees.

"We now have close to 100% compliance in the schools, and the kids are getting their physical education," he said. "I'm still working on the companies."

Around the country, physicians are looking for ways to improve the management of diabetes and prevent the onset of the disease, which is increasing rapidly in prevalence. From 1991 to 2000, diabetes increased 49%.

"The epidemics of diabetes and obesity are clearly escalating in the United States," said Centers for Disease Control and Prevention Director Jeffrey P. Koplan, MD, MPH. "If we continue on this course for the next decade, the public health implications in terms of both disease and health care costs will be staggering."

Diabetes increased 49% during the last decade.

On the public health side, the CDC has long funded state diabetes control programs, and the topic is expected to be a hot one at the American College of Preventive Medicine meeting in February.

But as the numbers continue to get more ominous, some physicians are looking at what they can do outside of the exam room.

"We as a country need to start thinking in terms of what are the horrible alternatives of not doing anything," said Dr. Menchaca.

Exam room to community

Some physicians are becoming more vocal about public policy. Others are working to improve their links with the community.

Kamlesh Gosai, MD, an internist in the small town of Bentleyville, Pa., where almost 20% of the local population is diabetic, has organized quarterly diabetes education fairs, arranged for discount YMCA memberships for his patients and provided money to maintain a local outdoor track.

The staff of his Southwest Medical Center goes to high-rise buildings and grocery stores to screen for the disease. He is also in negotiation with the school administrator to allow his nurse practitioner to use school facilities for exercise classes that would be open to everyone in the town. "We are a primary care, private medical practice so there's only so much we can do. I only have so much time," said Dr. Gosai. "But I'm part of the community."

Others are looking to create whole programs to combat diabetes in vulnerable groups. Deborah Burnet, MD, a University of Chicago internist and pediatrician, is helping organize classes in fitness at the local gym and in nutrition at a neighborhood grocery store. The classes are meant for minority families who are much more vulnerable to the disease and have at least one overweight child.

"There's a myth in our society that it's all personal choice," said Dr. Burnet. "It's important to work, not just on the individual level, but also on the family level, the community level. I see too many families that are overweight and then have [health] problems, including diabetes."

Some physicians have gotten involved in state-operated diabetes task forces that advance ideas such as giving incentives to companies that provide exercise opportunities, ensuring that sidewalks are a part of urban planning, and taxing high-fat food much like cigarettes.

"Fish is three times more expensive than beef," said Robert Greifinger, MD, a public health consultant based in Dobbs Ferry, N.Y., who facilitates diabetes coalitions in his region. "We need to find ways to have the marketplace make healthier food more attractive and more available. Particularly with poor people we need to reduce the barriers to healthy food."

But experts concede that while there is agreement that even moderate exercise and small weight loss can reduce the rate of diabetes and improve the situation of those who already have the metabolic disorder, there is little agreement on how to convince people to change their lifestyles.

Some talk about improving and increasing the availability of recreational facilities but are not sure if people will use them. They also talk about more sidewalks for walking and safe places for kids to play, but are not sure what impact those changes will have. And they talk about increasing the availability of healthy food, but are not sure how to convince people to choose it.

"I'm not one who wants to burn down McDonald's," said Charles M. Clark Jr., MD, chair of the National Diabetes Education Program and professor of medicine and pharmacology at Indiana University's Diabetes Research and Training Center in Indianapolis. "The food industry sells what people demand."

And there is little evidence that any of the interventions will work to improve people's health.

"The proof in the pudding is the outcome," said Dr. Menchaca. He will be returning to his local school district within the next couple years to investigate if the physical education requirement has made a difference.

No physician involved in community efforts, however, believes that it is possible to tackle the diabetes epidemic without back up.

"Physicians can't do it alone," said Dr. Clark.

"But they really can be more active as leaders in their community to raise the public knowledge and interest about the fact that there're a lot of public health issues that can be dealt with in the community."