The steady dirge of diabetes swells all about us, dark and onerous: the condition is now estimated to affect 7 percent of the population, with some putting the figure closer to 10 percent; with new molecular diagnostics, the numbers get even grimmer, with pre-diabetes—a state of risky blood sugar levels and inflammatory agents—edging in on 20 percent of the population. It is no surprise that a UCLA professor this past week called the numbers “the tip of the iceberg.”
Or is it the beak of the finch? When a condition that can lead to disability and premature death affects so large a part of a population, what’s really going on?
One way to think about Type 2 diabetes is to think of it as evolution in our own time. Think about Darwin’s tale of the finch with the short beak, the one that couldn’t crack the best nuts on that arboreal 19th century isle, and so died out, acceding its place to the finch with the curved, long beak. Type 2 marks the human finch—the ones whose hungry genes and challenged pancreas can’t keep pace with today’s calorically imbalanced world, a world where we are rewarded for over-consumption (sugary fatty foods are cheap and everywhere abundant), and our jobs pay us to be sedentary. Most of us are pre-finches.
This dynamic has unfolded at least once before, in western Europe of the post-Renaissance period, when crop yields exploded, personal fortunes grew, and famine—the evolutionary driver of our of genetic propensity to acquire and store calories via the so-called hungry gene—became less frequent. This produced a growing population—mainly the rich and the new upper middle class—who began displaying all of the symptoms we now recognize as diabetic: incessant unquenchable thirst (the merchant-humanist Alvise Cornaro), numbness and pain in the extremities (often in the form of gout or metabolic arthritis), loss of sight (Bach, a diabetic, went blind), and, eventually loss of limb to infection (see any number of merchants, nobles, and artisans). Importantly, it also produced the first literature of public and occupational health, with an emphasis on hygiene, self-control and more diagnostically-attuned physicians.
This “cryptic epidemic” of type 2 diabetes, as the scholar Jared Diamond has dubbed it, may well explain present-day Europe’s relatively mild increases in type 2 diabetes. In terms of evolution, the continent has already been winnowed, the hungry gene at least partly eliminated, producing a population less vulnerable to the caloric hammer now banging away at the metabolisms of the rest of the world. The European poor—the 19th century’s version of today’s Latin American immigrant—brought their hungry genes to America, where they still party on.
Of course, we are not finches; even better, and we are not 18th century burghers, who likely believed that their illnesses were somehow linked to the stars, Galenic humors, atmospheric miasmas and the twists of Fate. We are, at least in the case of type 2, engineers of our own evolution. Humans have invented relatively inexpensive tools to mitigate the ravages, or at least to grease the evolutionary pole.
In 1965, the first of these tools, the prototype of today’s glucose meter, came into circulation. Today the palm-sized meter, lancet and strips allow the average individual to determine and chart exactly how his or her metabolism is reacting to the modern environment of “diabesity--”obesity and diabetes. The meter is not—to anticipate the endless criticism of the medical and public health establishment—a “cure-all;” as Gina Kolata noted in a recent NY Times series, there’s more to treating and preventing diabetes than controlling blood sugar. But the meter gives us an evolutionary edge of which Bach’s physician never dreamed.
It’s not as easy to determine the origins of the second tool to mitigate our glucose-evolution, the pedometer, or step counter. It’s inventor may have been Thomas Jefferson (my choice), or Leonardo DaVinci ( my wife’s).What we do know is this: if your pedometer counts up fewer than 10,000 steps a day, your blood sugar can more easily get our of control. Beleaguered public health officials also know this: the pedometer is cheap and easy to understand, and serves an important psychological purpose as a prompt and a signal to a better chance of survival. That’s why you see them popping up everywhere.
Nevertheless, tools without teachers—and the social and medical environments to support them—don’t work. That is why California health officials, on the leading edge of the diabesity fight, are pressing for a smarter, earlier and more sustained focus on glucose control. Much of this dynamism comes from LA’s main medical institutions, UCLA and USC, whose underfunded teaching hospitals are in constant contact with the main Darwinian victims: the poor and the recently arrived.
Unfortunately, much of the consensus about what to do gets snared in endless policy debates about children’s medical insurance, state budgets, and what might be called “anti-stigma” ideology—the notion that any recognition of a health problem in a specific community will end up saddling said community with a negative image—the immigrant, say, as destroyer of public health, the fatty as Medicare-killer.
Fortunately, we’re moving beyond that nonsense; in fact, focusing on glucose control may be one way to get the health message of obesity across without getting it messed up in the chubby politics of victimhood and identity. Here is one idea: teach every ninth-grader how to use a glucose meter, and use the state’s vast negotiating power to make the devices nearly free for every family. Next: Show every 5th grader how and why to use a pedometer—and then give them one for free. Third: include a simple, glucose-control element in any application to immigrate to this country, with an emphasis on poorer immigrants. Lastly, appoint and fund a national diabetes Czar.
On this last, I can already hear the usual suspects screaming the inevitable Big Governmento. We’ll be sure to send them the national health care bill in 2020.
Greg Critser is the author of Fat Land: How Americans Became the Fattest People in the World, and the forthcoming Eternity Soup: Inside the Quest to End Aging (Harmony/Random House)