Donato Tramuto, Physicians Interactive, Healthways & Health eVillages
Yasmine Winkler, UnitedHealthcare
Jordan Shlain, MD, Institute for Responsible Nutrition, Healthloop
Scott Bowman, Clareo
Diabetes is the “flip side to a good story,” notes Novo Nordisk’s Niels Lundwryly. Strengthening economies, the trend toward urban living (more than half the world’s 7.3 billion people now live in cities) along with stunning achievements in taming infectious diseases mean that more people are living long enough to develop chronic conditions such as diabetes. Car-dependent lifestyles, sedentary jobs and diets dominated by sugar and salt-laden processed foods have contributed to the risk, as witnessed in dramatically rising rates of obesity. It has been called “a disease in slow motion,” yet one that has already reached pandemic levels.
Ironically, diabetes is both an affliction of the the prosperous and of the poor, who cannot afford prevention, says Lund. Today, the number of people with diabetes is fast approaching 400 million globally, though only about have have been diagnosed. Even more disturbing, half of those cases go untreated and only half of those cases being treated are under control. By the time all the numbers are diced and sliced, a mere 6% of diabetics are living lives free of disease-related symptoms.
Lund, Vice President of Corporate Affairs, has joined forces with partners University College London (UCL) and Denmark’s Steno Diabetes Centerto create an urban-centric public health assault on the spread of diabetes--Cities Changing Diabetes—designed to shift what are currently seen as risk factors into opportunities. As state and federal governments around the world become increasingly gridlocked, cities have emerged as significant centers of power. Over the next decade, 136 new cities—all in the developing world—will enter the list of the 600 largest cities, says Lund, citing a McKinsey study, so finding ways to harness that power could be key not just for slowing the spread of diabetes but potentially for reversing trends and cutting the numbers of cases.
It is an ambitious goal and one for which Novo Nordisk is uniquely positioned among pharmaceutical companies to lead. Run by a foundation, the company can afford take a long arc view of its mission. Although its medicines and services help an estimated 24 million patients, that is still only a small percentage of the world’s diabetics. Short terms goals to reach more patients can be pursued in conjuncture with the long term goal to stamp out the disease altogether.
Five cities have been chosen to pilot the initiative, each highlighting different issues and health care systems: Copenhagen, Houston, Mexico City, Tianjin and Shanghai. Acknowledging that “the plane is being built as it is flying,” Lund outlines the project’s three-tiered approach:
First, map the extent of the urban diabetes, noting contributing factors and the success of various public health interventions
Next, build a database to share results while leveraging global networks to move diabetes up the global public health agenda
Finally, implement action plans and develop ways to scale successful ideas to other cities
Cities Changing Diabetes is a pioneering public health effort on many levels, including its work with anthropologists to gain insight into the social logistics of diabetes’ spread. Architects and urban planners along with other unconventional stake-holders are also being welcomed to the table. Notes Lund, cities that are designed to promote more walking and bike-riding embed better fitness right into the urban fabric.
“The more ‘collaborative IQ’ in health care, the better,” agrees Donato Tramuto, CEO and Chairman of Physicians Interactive, a multi-channel life sciences marketing platform, and Chairman of Healthways, a leader in disease management and proactive health strategies. “It’s not about innovation, but integration,” he says, pointing out that only a tiny number—perhaps 5%—of health apps gain traction with patients and the medical community. That lack of coordination has consequences that can upend the whole concept of helping the sick heal, he says. For example, while insurance companies can subsidize intravenous food programs for HIV patients, there is no mechanism for them to subsidize prescriptions for nutritional food.
Diabetes is a personal issue for Tramuto. When his father was 55 years old, he was diagnosed as “chronic stable.” Within 15 years, limbs were being amputated. “If he had been diagnosed earlier, he would have lived longer, been healthier and the medical costs would have been much less. The system skews toward treating chronic illnesses rather than preventing or minimizing them,” he says.
Community plays a crucial role in health, he says, citing studies on what have become known as “Blue Zone” populations where people naturally live longer, happier, healthier lives. It turns out that genetics only plays a small role. Of much more importance are good family and social networks. Blue Zoners are also less reliant on cars, so walk more. Many also drink a glass of wine a day. Notably, both activities are social. “Community means understanding,” says Tramuto, a sense of connectedness, belonging and purpose.
Building on this insight, Health eVillages, founded by Tramuto in the wake of the earthquakes in Haiti, develops programs that provide community health workers with mobile health solutions to improve outcomes in poor communities. By training people already living in these communities as health workers and equipping them with, for example, iPads pre-loaded with medical information, public health can take a proactive role. In one East African “village” (population 50,000), Tramuto notes, infant mortality rates were reduced by two thirds, from 100 to 35 deaths per one thousand births through such an effort.
Building on the power of community is behind one of Healthways efforts in the US, where a shocking low percentage of us—just 2 in 10,000—qualify as Blue Zoners. The company contracted with 11,000 health clubs to provide free access for senior citizens enrolled in its programs. A slow time for gyms— 10 am to 2 pm—turns out to be prime time for seniors and working out becomes more of a social event.
Yasmine Winkler, Community and State CEO for the Central Region and Chief Consumer Officer for UnitedHealthcare, agrees that positioning fitness as a social activity rather than a “good for you” activity is key. When the insurance company partnered with the YMCA to set up a Diabetes Prevention Program, the word “diabetes” turned out to be a turn off. The program had to be repositioned to focus on goals with which people could more easily identify, such as losing weight. She also agrees with the importance of bringing more community health workers into the mix, citing Cuba as a case study on the “interconnectedness of care. Clearly, new ideas are urgently needed: “Diabetes ranks in the top three diagnoses among Medicaid, Medicare and business customers,” she says.
Dr. Jordan Shlain, a practicing physician, digital health entrepreneur (Healthloop) and founder of the Institute for Responsible Nutrition, underscores the importance of language in trying to control diabetes. The word diabetes, he points out, is Latin for “syphon,” referring to a common symptom noted millennia ago of frequent urination. More fitting, he thinks, would be if the condition were linked to a primary cause and rechristened “Processed Food Disease.” “You don’t get diabetes. It’s self-inflicted,” Shlain says. “Once you have it, you’re done. You can only optimize for it.”
There is so much sugar in so much of what we eat, says Shlain, that “now we have dessert for breakfast lunch and dinner,” while “conflational science” has obscured the truth about good and bad sugars. “Fructose goes through the same process as liquor to be metabolized, leading to fatty liver disease, which is metabolic disease in kids,” he explains. “'Natural cane juice’ is another way of saying “added sugar.” Further complicating the dietary picture, sugar and salt are added to fat-free foods to make them palatable, so what seems like a smart healthy choice, actually is not. Skinny people, he points out, can have visceral fat, which though out of sight, is just as deadly.
Shlain calls for a “Real Food" certification program designed to make it easier for consumers to see the truth beyond the packaging and for companies to explore ways to subsidize healthy food purchases by employees that can prevent and control diabetes, which in the long run will prove cheaper than subsidizing medicines.
Business as usual means that the number of diabetics in the world will spike to a half billion by 2035, according to Novo Nordisk, if not sooner. That does not take into account the toll on their families and communities. From lost quality of life to lost income, diabetes is a global blight, yet one for which there is much we can do to turn to the tide. It will take a concerted, comprehensive, multifaceted, multi-disciplinary approach—probably a range of approaches that can change all of our lives for the better.