Dr Chris Feudtner is assistant professor of paediatrics at the University of Pennsylvania School of Medicine in the United States of America. As a researcher he has focused on understanding the epidemiology and health-care experience of children with complex chronic conditions, with a particular emphasis or] palliative, end-of-life and bereavement care, as well as hospital in-patient care. He received his Doctor of Medicine and Doctor of Philosophy in the history of medicine from the University of Pennsylvania in 1995, and completed his residency in paediatrics at the University of Washington in 1998. He has published dozens of articles, as well as the book, Bittersweet: diabetes, insulin and the transformation of illness in 2003.
Q: Why has diabetes become a major threat to global health?
A: People with Type 2 diabetes produce an abundance of insulin in response to an environment that allows them to ingest more calories than ever before without many physical demands, such as walking, cycling and physical work, while leading a rather sedentary lifestyle sitting at a desk. This combination of excessive amounts of calories coming in and a paucity of calories going out leads people to gain weight and become obese. We have seen this imbalance in the developed world since the 1930s, leading to the rapid rise of Type 2 diabetes in the 1980s and 1990s. But now also in the developing world the amount of high caloric food that some people eat far exceeds their requirements and so the epidemic is spreading.
Q: In what sense is Type 2 diabetes a product (technology and our lifestyle?
A: Technologies such as those involved in food production, farming and food processing, allow people to ingest more calorically-dense food than ever before in far greater amounts. We are talking about food stuffs that didn't even exist until recently. In contrast, it is actually hard to overeat traditional foods such as rice. "Then there are transportation technologies, which enable people to avoid walking, and also the shift from manual labour to machines. These technologies have shifted the amount of energy that people expend in doing their daily business. In sum, technology has given us this surfeit of calories and dearth of energy expenditure. I am not suggesting that we should be Luddites and go back to subsistence farming and walking everywhere, but we have to deal with the consequences of pushing our metabolism beyond what it is capable of handling.
Q: What about the positive advancements of technology?
A: When people consume an excess of calories they wind up needing another set of technologies that can identify whether they have diabetes. While this technology is wonderful, it is ironic. Screening technologies allow us to very quickly identify people who are at risk of diabetes but haven't yet manifested symptoms. We can then treat those patients with diet modification recommendations and oral drugs.
Q: But shouldn't we be focusing more on prevention and not just on treatment once the condition has developed?
A: Most drugs are to manage diabetes once people have developed it. We don't have the array of drugs we would like to have to prevent mild metabolic derangement from progressing to diabetes.
Q: Why? Is there no incentive to produce drugs for prevention for companies already producing treatment drugs?
A: Several business incentives do indeed depend on people having diabetes, on treatment rather than prevention, but this may change. The story of the diabetes epidemic and our social response to it is one of how technologies have pushed people into a diabetic state: technology has wrought more technology. Is this really the way we want to use the tremendous potential of medical science? Yet jumping off this seemingly endless regress of technology dependence is not easy: I doubt that you can tell people to live simply. …