American medicine is undergoing the greatest financial scrutiny in its history. The hue and cry for reform stems primarily from the soaring costs of health care. However, placing the blame for these costs solely on increased utilization of technology, cutting-edge pharmaceuticals, cost-shifting hospitals, and physicians misses a bigger mark.
A HEAVY PRICE TO PAY FOR TYPE 2 DIABETES
Let's look at a relatively expensive and prevalent disease, type 2 diabetes mellitus. Pelletier and colleagues1 assessed the costs of this disease and its multiple complications. Myocardial infarction, heart failure, and renal disease occurred in 7.2%, 14.0%, and 11.0%, respectively, of a large but typical cohort of patients with type 2 diabetes. The 12-month mean cost per patient who experienced each complication was $41,695, $30,066, and $34,987.
The population burdened with type 2 diabetes is on the rise, as are these and other expensive complications (including retinopathy and dialysis). This fact alone suggests that costs will also continue to increase. Where do we begin to seriously impact this epidemic and its contingent costs?
A TICKING CLOCK—OR TIME BOMB?
The clock, or rather time bomb, for type 2 diabetes starts ticking in childhood. A recent study included a cohort of 1067 girls, entered at age 10 years in the National Growth and Health Study, and 822 additional schoolchildren, aged 6 to 18 years, from the Princeton Follow-up Study.2 Noninvasive, office-based parameters typically screened for in primary care—blood pressure; body mass index (BMI); and fasting glucose, insulin, and lipid values—could already predict which children and adolescents would later have type 2 diabetes (at ages 19 and 39 depending on which of the 2 groups was reported).
A breakdown of select "numbers" can be helpful. Looking at weight as a predictor of type 2 diabetes, a BMI in the top fifth percentile made it 4 times more likely that diabetes would occur in adolescence or adulthood. Taking elevated blood pressure as an independent predictor, a systolic pressure in the top fifth percentile increased the risk of later "full-fledged" type 2 diabetes an impressive 5.78 times.
Although it is wrong to say that children and adolescents are "little adults," the milieu typically associated with type 2 diabetes in adults—hypertension, obesity, and insulin resistance—starts wreaking havoc in childhood and does not seem to go away. Unless recognized and treated early, type 2 diabetes and cardiovascular and renal diseases, as well as their attendant costs, will continue to rise. But what treatment is indicated?
NEED FOR REFORM NOT LIMITED TO HEALTH CARE SYSTEM
The answer is inescapable: lifestyle change is necessary and that prescription is not limited to adults. In fact, by late adolescence and adulthood, significant damage may already have occurred as a preliminary to the later ravages of type 2 diabetes. A rich lifestyle across a spectrum of ages seems to need aggressive reform too.