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In 2005, the US Department of Veteran Affairs, conscious that an estimated seven in 10 veterans were overweight or obese, launched a programme called Move to encourage weight loss through lifestyle change – a better diet alongside more exercise.
Two years ago, researchers published an analysis of the results: a dismal 5 per cent of eligible candidates participated in the programme, and for those who did, its effectiveness was low, with participants losing 0.9lbs more on average than non-participants after a year.
The Move scheme was not aimed solely at combating diabetes, but what it found – the sheer difficulty of persuading people to change the way they live – is among the biggest challenges facing type 2 diabetes prevention programmes.
While meta-analysis of research shows that even modest weight reduction is the best way to reduce both the risk of developing type 2 and to fend off its most devastating effects among those already diagnosed, achieving this is no simple matter. In fact, no country in the world has managed to reduce obesity across all age groups – though some have seen it plateau in one subset of the population or another. “One of the most challenging aspects of type 2 diabetes prevention remains the general application of positive results from clinical trials,” write the authors of Diabetes UK’s nutrition guidelines. “There are ongoing studies investigating different strategies in the community but at present there is little evidence in translation of the success of randomised controlled trials to public health.”
Part of the problem, Diabetes UK admits, is that while weight loss is the clear goal, no evidence supports one particular dietary strategy over another. “We are not into the more quick-fixy end of things. So we say it’s important to have a good, well-balanced diet with a good mix of fruits and vegetables, but we don’t get into the superfood stuff,” says Robin Hewings, head of policy at Diabetes UK.
But others are frustrated by that approach. Jessica Apple, founder of the diabetes non-profit and online magazine ASweetLife.org, is a strong advocate of a low-carb diet and believes organisations such as the American Diabetes Association are doing people a disservice.
“The biggest problem is that people don’t understand that whether you’re eating a bag of candy or a big plate of pasta, your body is doing the same thing with it.” She points to recipes recommended by the American Diabetes Association that replace butter – which has no impact on blood sugar – with apple sauce. “A low-fat diet is still held up as the model.”
That is not to say she believes adopting – or even advocating – such a diet is easy. Culture is one problem, with many of the highest risk groups living in areas without easy or affordable access to healthy food. Moreover, it is difficult to tell someone raised on rice and tortillas to switch to Greek salads.
The culture within the diabetes community can also play a role. Ms Apple says the mantra among many suffering from type 1 diabetes has long been: “‘I can eat whatever I want and cover it with insulin’. It’s a point of pride,” she says. But it is also a serious sticking point for any lifestyle programme.
Details of lifestyle-change regimes aside, one of the biggest challenges to real public health gains is the patchiness of the approach in most countries. While many Britons with early signs of the disease will get good advice, Mr Hewings spoke to one man recently whose doctor told him he had “a touch of diabetes”. Rather than send him to a weight-loss programme or even talk about ways of combating the disease, he said simply: “Let’s see how it goes”.
The UK’s National Health Service’s Five Year Forward View, published last month, aims to develop a national, evidence-based diabetes prevention programme. In the US, meanwhile, a big effort has been under way since 2010 to scale up lifestyle programmes – aiming to reach the estimated 86m (and rising) Americans with pre-diabetes.