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An opinion piece on the U.S. food system, medical landscape, environmental toxins, the rise of Ozempic, and the opportunities/limitations/data implications of digital health technology. Written from a public health perspective with analysis and recommendations to act and improve on this population health crisis.
Garrison Grant
February 20th, 2024
Opening and Overview:
Nearly half (49.6%) of American adults are now diabetic or prediabetic (Centers for Disease Control and Prevention, 2023). The most recent data from the 2021 CDC National Diabetes Statistic Report shows an 11.6% prevalence of diabetes and a 38% prevalence of prediabetes among U.S. adults, based on their fasting glucose or A1C level. Diabetes is a health condition that happens when your blood sugar (glucose) is too high (Cleveland Clinic, 2023). Diabetes develops when your pancreas doesn’t make enough insulin or any at all, or when your body isn’t responding to the effects of insulin properly. Diabetes affects people of all ages. Most forms of diabetes are chronic, and all forms are manageable with medications and/or lifestyle changes.
What is even more concerning is that here in the United States, we are “world leaders” in type 2 diabetes (T2D) among children and adolescents (Bloomgarden & Rapaport, 2023). A 2022 worldwide systematic review of published studies on the incidence of type 2 diabetes in children and adolescents showed the U.S. as a clear ‘frontrunner’ with 13.8 cases of T2D per 100,000 person-years. Compare this to 1.5 cases per 100,000 person-years in neighboring Canada, 0.7 cases per 100,000 person-years in the United Kingdom, and 0.1 cases per 100,000 person-years in Germany (Table 1).
These stark numbers exemplify how metabolically unhealthy our country is in 2024. So why are half of us here in the U.S. diabetic or prediabetic? Is it our food? Our environment? Our stress? Our sleep? I believe it is not one singular cause but a multitude of lifestyle factors contributing to what could be the greatest population health crisis of our lifetime. The good news is that both diabetes and prediabetes are reversible with weight loss and by adopting healthy eating and exercise habits (Bell, 2023). This blog post aims to provide analysis and recommendations for public health strategies to incorporate health information technology to adopt solutions in slowing and reversing this population health crisis.
Health IT Opportunities:
Digital technologies empower Americans to remain healthy outside the doctor’s office.
There are 525,600 minutes in a year. The average American interfaces with a health system for 100 minutes out of the year (Horoho, 2012), leaving us with 525,500 minutes per year spent making decisions that can either hurt or help our metabolic health.
For those with diabetes, continuous glucose monitors are amazing wearable devices and are used to measure insulin levels to give real-time updates through a device that is attached to their body (American Diabetes Association, n.d.). For those with prediabetes, defined as 100 to 125 milligrams of sugar per deciliter blood sugar value taken while fasting for at least eight hours, and for individuals with normal blood sugar value (less than 100 mg/dL) (Mayo Clinic, n.d.) wanting to prevent diabetes, digital wearable devices offer great hope to track overall health and fitness. Wearable devices are more popular than ever before, with companies and devices like Apple Watch, Whoop, Garmin, Fitbit, and Oura Ring leading the way. A nationally representative study of contemporary patterns of wearable device uses among US adults estimated that 72 million, or one-third of the US adults, used wearable devices to track their health and fitness (Dhingra et al., 2023). Whoop Research Labs indicate that organizations that use their device tracked 46% fewer days of alcohol consumption, 27% increase in days meditated, 59% improvement in fitness levels, and 52% increase in quality of sleep (Whoop, 2023). Wearable devices also inform users with key insights like continuously monitoring heart rate and blood oxygen level, along with other vital signs like resting heart rate and heart rate variability. They monitor how well you sleep, stress levels, and allow users to gauge how certain foods, alcohol, or caffeine affect energy and recovery. Wearable device services equip consumers with health data they can share via reports to their providers to give a 24/7 365-day view into their health monitoring.
Leverage Health IT to shift healthcare towards a preventative focus.
To slow down the rate of Americans with prediabetes and decrease prediabetes prevalence. reverse Reform healthcare so there is more of a focus on preventative medicine. Innovative companies like TrueMed are empowering consumers to tap into their HSA/FSA funds to pay for preventative steps to avoid diabetes and chronic illnesses (Truemed, 2023). They cover things like CrossFit memberships, bone broth, grass-fed meats, wearable devices, supplements, and peloton purchases. By improving the administrative logistics of obtaining letters of medical necessity TrueMed is an example of how a startup company can leverage technology to promote the use of preventative health practices.
Policy changes to promote the prevention of diabetes vs. the management of it.
Our current healthcare system is set up to focus more on the management of diseases than promoting the prevention of them. Many preventative and functional medicine services are not covered by modern insurance, even though many patients stand to benefit from preventative services (Lopez, 2023). Health coaching for example is not covered by insurance but can offer tailored plans for individuals to lose weight, eat healthy, exercise, and focus on preventing or treating the root causes of their diabetes. With the COVID-19 pandemic, we saw a migration into digital telehealth platforms to aid in the delivery of these services. Legislation can lean into the efficiency and accessibility that telehealth platforms bring by lifting state restrictions (Gajarawala & Pelkowski, 2021) and incorporating health coaching as a viable service worthy of insurance reimbursements.
Health IT Limitations:
A major limitation of the adoption of both continuous glucose monitoring devices and health and fitness wearable device trackers is their expense making them unattainable for lower-income individuals (Dhingra et al., 2023). There are also barriers for elderly individuals concerning technological accessibility and usability of the software interface and device functionality. Legal questions also come into consideration when thinking of expanding healthcare with further integration of consumer devices. In a scenario where a patient's continuous glucose monitor has a faulty reading, and the patient is harmed, who is liable? Is the company who made the device liable, is the patient, is their provider? These answers will have to be explicitly identified in a legal framework for providers, patients, and companies participating in the digital health landscape.
Data Implications:
Privacy concerns over confidential patient information are always a consideration. Currently, wearable device users can download a PDF to share with their providers. Data implications and questions about interoperability and protecting patient health information arise when thinking about the future integrations of consumer patient data with clinical providers. Will we see a time when patients can remotely share their health data in a way that is synced to their provider's EHR system? If so, many security measures must be in place to minimize the risks of data breaches and leaks of patient health information. When using a doctor to share health information to obtain letters of medical necessity online it is imperative that the data a consumer shares is protected and the flow of information on the websites are encrypted. Additionally, when expanding telehealth to include health coaching, billing codes must be set up and strict security and legal guidelines will need to be created and implemented consistently.
Recommendations and Analysis:
My recommendation and analysis for preventing further growth and ultimately reducing the prevalence of diabetes and prediabetes in our country is to take a multi-pronged approach to how we are communicating and framing diabetes as a society in our country and to leverage health information technology to improve health outcomes.
We should promote the communication of diabetes as a chronic illness that can be avoided with preventative factors and reversed with behavior change and lifestyle adjustments. While medical interventions like bariatric surgery and weight loss drugs such as Ozempic and Wegovy can be effective, they should not be promoted as the first and only options. If we view Ozempic as a “miracle drug” while paying little attention to the quality of our foods, we will continue to live in a country of managing disease and will likely see a continued rise in diabetes prevalence. From a public health standpoint, we will be much better off long term if we can educate and promote a culture of positive behavioral lifestyle changes as a way of preventing and reversing diabetes rather than reliance on a magic drug requiring weekly injections for life (Wilding et al., 2022).
We should harness digital technology innovation to empower individuals to become the “CEO” and actually "Chief Health Officer" of their own health. We spend almost all our time outside of the doctor’s office, so having tools to give us more data and access to health coaches and preventative practices on how our lifestyle choices make us feel can encourage individuals to continue to make healthy choices and can lead to the prevention and potential to reverse prediabetes and diabetes in some cases.
Finally, although not having much to do with digital health technology but is relevant at a population health level, our environment plays a massive role in our health and in the prevention of chronic diseases (Centers for Disease Control and Prevention, 2019). We need to crack down on environmental toxins. This can be done at a household level by educating and becoming aware of chemicals in household products, of the heavy metals and pesticides found in food and beverages, and monitoring the quality of our water and air. Additionally, on a governmental level, we need to do a better job at regulating and banning pesticide use in our food supply. Glyphosate is the most widely applied herbicide worldwide, and its use has been associated with increased risks of certain hematopoietic cancers in epidemiologic studies (Chang et al., 2023). By reforming our food system, we can shift subsidies away from commodity crops that require pesticides to obtain a high yield, ending up in processed foods, contributing to our diabetes epidemic. We can promote and shift subsidies towards whole foods, fruits and vegetables, and regenerative farming practices that are restorative for the land and more nutrient-dense, resulting in healthier foods for our population.
Thank you for making it this far. It can be discouraging to look at this extreme population health problem facing our country but many people are fighting to find viable solutions. I wrote this blog for my Health IT, Informatics, and Decision-Making course as part of my degree requirements for my Masters of Public Health Student at George Washington University. My background is in marketing, mental health advocacy, and public health communication. I am working on my thesis paper entitled “Assessing the Ketogenic Diet as a Dietary Intervention for the Treatment of major depressive disorder, schizophrenia, and bipolar disorder and What it Means for the Future of Public Health.” If you feel you resonate with this blog, have recommendations, want to share a different point of view, or chat about anything else please reach out to me at letschataboutit.com or send me an email at garrison.grant@gwu.edu. I hope you found some value and positivity in this!
Cheers,
Garrison Grant
References
American Diabetes Association. (n.d.). Continuous Glucose Monitors (CGM) | ADA.
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Bell, A. (2023, November 22). Can diabetes be reversed? | research spotlight. UCLA Med
Bloomgarden, Z., & Rapaport, R. (2023). Diabetes trends in youth. Journal of Diabetes, 15(4),
Centers for Disease Control and Prevention. (2019, February 20). Introduction toEnvironmental
Public Health Tracking. Www.cdc.gov.
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Centers for Disease Control and Prevention. (2023, November 29). National diabetes statistics
Chang, V. C., Andreotti, G., Ospina, M., Parks, C. G., Liu, D., Shearer, J. J., Rothman, N.,
Silverman, D. T., Sandler, D. P., Calafat, A. M., Beane Freeman, L. E., & Hofmann, J. N.
(2023). Glyphosate Exposure and Urinary Oxidative Stress Biomarkers in the
Agricultural Health Study. JNCI: Journal of the National Cancer Institute, 115(4).
Cleveland Clinic. (2023, February 17). Diabetes. Cleveland Clinic; Cleveland Clinic.
Dhingra, L. S., Arya Aminorroaya, Oikonomou, E. K., Arash Aghajani Nargesi, Francis Perry
Wilson, Krumholz, H. M., & Khera, R. (2023). Use of Wearable Devices in Individuals
With or at Risk for Cardiovascular Disease in the US, 2019 to 2020. JAMA Network
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Gajarawala, S., & Pelkowski, J. (2021). Telehealth benefits and barriers. The Journal for Nurse
Practitioners, 17(2), 218–221. https://doi.org/10.1016/j.nurpra.2020.09.013
Horoho, P. (2012). WRITTEN STATEMENT OF LIEUTENANT GENERAL PATRICIA D
HOROHO THE SURGEON GENERAL OF THE UNITED STATES ARMY AND
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Lopez, M. (2023, November 13). State of the Health Coaching Industry for 2023. AFPA.
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Truemed. (2023). Use FSA/HSA dollars for healthy food, exercise, supplements, and more.
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I., McGowan, B. M., Oral, T. K., Rosenstock, J., Wadden, T. A., Wharton, S., Yokote, K.,
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Appendix
Table 1: Worldwide T2D Incidence in children and adolescents in 2021
