Newsletter | The Shameful Epidemic of Diabetes

Nearly 15% of American adults now live with diabetes. That’s a 15-fold increase over the course of 2-3 generations. Nearly 30% of Americans over 65 now have it. As an epidemic it has grown consistently and relentlessly. It is a national tragedy. It is also a massive industry.

Two recent articles by Neil Barsky in The Guardian speak to both the human and the societal costs of the epidemic. In More than 100,000 Americans with diabetes have limbs amputated each year. This is a crisis, Barsky focuses on the tragedy of diabetes-associated limb amputations by interviewing people living with the disease and sharing their stories. It is a visceral portrait of the inequities of the US health care system and an indictment of our collective failure to prevent the onset of the disease and its progression. Black Americans are four times more likely to have a limb amputated than White Americans; the same ratio holds true for less affluent and affluent Americans. It is a disease for which the socioeconomic factors that generate inequitable opportunities for health behaviors and that lead to inequitable access to quality health care compound tragically.

Barsky asks why there isn’t more urgency to fix the problem and answers his own question by pointing the finger at the industry that has developed around the disease. He notes that the American Diabetes Association (ADA), the leading nonprofit organization that aspires to end diabetes, works closely with (and accepts money from) the pharma companies and device manufacturers that ultimately capture a share of the now $400 billion Americans annually spend on diabetes-related medical care. In the second article, The FDA chief is right: we are failing people with diabetes, he covers FDA Commissioner Robert Califf’s keynote at the annual ADA conference. As the headline suggests, Califf didn’t mince words, but largely argued that the problem is one of insufficient labeling of unhealthy food products and a general failure of digital health tools to deliver meaningful benefit to most diabetes patients. Barsky, who was himself diagnosed with type 2 diabetes and managed to reverse it with dietary changes, laments Califf’s failure to advocate for what he sees as a simple and effective solution: the adoption of a low-carb diet. 

As Barsky acknowledges, a national dietary shift away from carbohydrates is a tall order and made taller by the interests and incentives that guide many of the key industrial and political actors. A more American solution to the problem – using technology to fix it – emerged with the recent development of GLP-1 agonists like Ozempic, Wegovy, Mounjaro and the like, that have demonstrated remarkable effectiveness, albeit at high costs and low retention rates. This NPR account of how Ozempic's popularity is leading to shortages for people with type 2 diabetes highlights how marketing from the pharma companies about the weight-loss benefits of the drug has stoked demand for its use for cosmetic weight loss. The extraordinary business success of these drugs has even led to global economic impact, with Novo Nordisk (makers of Ozempic and Wegovy) now accounting for 1 in 5 new jobs in Denmark. Economically speaking, these are ideal drugs for the manufacturers, requiring ongoing use to manage diabetes and obesity, conditions with enormous prevalence.

The food industry, which largely escapes Barsky’s wrath, is not likely to jump on the low-carb bandwagon. That’s an inescapable conclusion from reading Nicholas Florko’s piece What I learned about ultra-processed foods from stuffing my face at the world's leading food technology event. Florko attended the Institute of Food Technologists’ IFT First conference and got a glimpse of how that industry is thinking: AI is being used to design the perfect food; contemporary child-rearing trends can affect the sort of “indulgent” snacks kids will want to consume; fears about ultraprocessed foods are creating new market opportunities. His summation: “[the industry] is marching ahead with intentionally and strategically designing edible creations so craveable you might set aside your nutritional concerns.”

The different interests form a pernicious context that has enabled the disease to thrive. Too often, there is shame associated with diseases that are rooted in individual behavior – and indeed, some of Barsky’s interviewees discuss a sense of personal shame. At Building H, we reject the idea of blaming individuals for systemic failures. The shame we should all feel is the collective shame of a nation allowing this epidemic to happen, causing widespread suffering and death, and then turning the problem back to individuals who face enormous barriers and who must battle entire industries hell bent on getting them to make unhealthy choices. This shame results from our failure to confront the dynamics that foster the spread of type 2 diabetes. The food industry engineers its products (and pitches its advertisements) to ensure their craveability exceeds any rational health concerns their customer might have; the medical industry — particularly pharma, device manufacturers and hospitals – need their products and services to be effective at combating diabetes while not so successful as to eliminate the need to combat it at a large scale. Nonprofit advocacy and support organizations need funding to survive and thus many of them can’t do too much to alienate the industry players that fund them. And political actors, above all, value a flourishing economy and having both industries that profit from creating diabetes and others that profit from treating it amounts to a win-win. (In an absurd twist on that logic, Denmark’s economic security is now linked to maintaining high levels of obesity and diabetes in the US.)

These forces coexist in a kind of tension that holds the problem of diabetes in place, that yields the hundreds of thousands of stories of people suffering from amputations and many more who suffer from other complications. But these forces ultimately result from an economic system, based on a set of rules, that we choose. We can choose to double down on that system – to expect that the forces that create the problem will also generate the solution. Or we can choose differently and reimagine that system such that it wouldn't generate such tragic illness in the first place.

What would you choose? Comments are open below.

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