America's "Obesogenic" Mess

An editorial published online this week by the New England Journal of Medicine¹ caught and has held my attention. It is a comment on results of the TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) study² and the potential blow these could deliver to what we tell our patients, of all ages, every day about the role of lifestyle change in the prevention and lifetime management of type 2 diabetes (T2DM).
 
Given comments I recently made elsewhere on the newly published ADA/EASD 2012 position statement³ and its clear emphasis on improved lifestyle choices as the foundation for successful management of T2DM, announcement of the TODAY results and this editorial struck home.

The study followed patients aged 10 to 17 years who had received a diagnosis of T2DM less than 2 years before entering the study; had a body mass index (BMI) above the 85th percentile; and met criteria for additional metabolic markers.² The primary objective was to compare 3 treatment groups with respect to treatment durability (measured as loss of glycemic control): metformin alone; metformin plus rosiglitazone; and, metformin plus intensive lifestyle intervention. Disappointingly for advocates of healthy choices for a lifetime, the metformin/lifestyle intervention failed to significantly improve glycemic control or produce laudable weight loss.²

Are the results, in part, a strike against clarion calls for increased physical activity and reduced caloric intake among America’s kids? Nothing of the kind, according to editorialist David Allen, MD, of the Department of Pediatrics, University of Wisconsin School of Medicine and Public Health. Instead, Allen says, they underscore-and painfully-the mess we face as a nation overwhelmed by “chronic caloric surplus”² and an untold variety of barriers to fixing the problem.


I happen to agree with Dr Allen. We are in a "mess"; an obeseogenic² environment that makes it much easier to opt in to unhealthy lifestyle choices and far more difficult to opt out of the existing social norms. When I grew up (never mind the dates), I had very few lifestyle choices to make. If I chose to eat, the food presented to me was pretty healthy and definitely bore no resemblance to the calorie-rich choices served up in so many pre-prepared and fast-food meals. If I chose to go somewhere or be with my friends, I rode my bike or walked. In fact, the majority of our playtime involved walking, riding, or moving. And now that I think about it, "playtime" usually consisted of being locked out of the house, after getting home from school and putting your stuff up, until dinner was ready. If you want to get a good feeling for what it was like "back then," I highly recommend Bill Bryson's excellent book The Life and Times of the Thunderbolt Kid⁴ about a childhood in small-town Iowa in the early 1950s. The world today is quite different and places our children in a lifestyle environment where the unhealthy choice is easy to make.

As editorialist Allen says, the TODAY study¹ is not a condemnation of lifestyle change, but a stark vision of how difficult it is to bring the promise of healthier choices to fruition in the world we now live. Certainly, our children with type 2 diabetes must be offered a better way to good health than a lifelong dependence on pills and injections.

Maybe this study shows us just how good healthy lifestyles have always been-and confronts us with what has been lost!

References
1. Allen DB. TODAY-A stark glimpse of tomorrow [editorial]. N Engl J Med. Published online ahead of print. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMe1204710. Accessed April 30, 2012.
2. Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med. Published online ahead of print. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1109333. Accessed April 30, 2012.
3. Inzucchi SE, Bergenstahl RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient centered approach. Diabetes Care. Published online ahead of print, April 19, 2012. Available at: http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf. Accessed April 24, 2012.
4. Bryson B. The Life and Times of the Thunderbolt Kid. New York: Broadway Books, an imprint of the Doubleday Broadway Publishing Group, a division of Random House; 2006.