Sorry for the hiatus... you would think all of the plane travel to and from Las Vegas would give me plenty of time to write. I do have some ideas that I have stored away and I hope to get them out in the next few hours to days.
Constant flying has afforded me one unique opportunity--the necessary need to disconnect from screens (iPhone/iPad/Mac Book Air) for just a few minutes when we are taking off. Although the evidence around this policy is shoddy at best, I have learned to pack real live printed materials to entertain me during the endless waiting between sitting down and plugging back in. Most often, journals such as Health Affairs or the New England Journal of Medicine fill this time.
The January issue of Health Affairs, a well-respected, in-depth monthly look at health policy research and proposal, focused on Diabetes as the theme for the issue. As usual, a collection of well-thought out and well-intentioned articles fill the pages of this journal, examining the effects of existing laws and programs, and proposing new, population wide strategies to combat disease and improve health. Prominent among the articles were suggestions of financial incentives (or taxes) on certain individual behaviors to promote a lifestyle that would avoid diabetes. The usual suggestions of taxing sodas to save the world were laid forth. What struck me the most about this issue was not what was suggested, but what was ignored--the food supply.
In the typical policy attempt to draft smarter and better regulations to more adeptly mold human behavior to fit some vision or another, new laws and new restrictions are always proposed. In an almost comically predictable fashion, there is almost zero evaluation of previous programs or policies with the same intended consequences, and even more sparingly, evaluation of seemingly unrelated laws with disastrous consequences. In this case, in over 200 pages on proposals for policy changes on diabetes, I could find only 1 paragraph discussing the laws that govern our food supply.
While Diabetes is a multifactorial condition (code for we have some great ideas but no clear mechanism of disease), it is indisputably linked to food consumption. There is a stark correlation between changes in the American (and subsequently the world) food supply towards corn and corn-derived food sweeteners and a shocking increase in diabetes. (Again, correlation, not causation). So why go after corn? It turns out that the reason for the shift away from sugar to corn is the result of, you guessed it, former public policy decision in the United States. I am not talking about health regulations, but about farm subsidies.
It is US Agricultural policy that determines that corn is cheap and plentiful, and its derivatives fill our groceries stores and stomachs. Does this cause diabetes? I do not have convincing evidence, but enough suspicion to voluntarily choose to avoid the stuff whenever possible and advice friends, family and patients to do the same. To be honest, ever since we covered how well the body regulates glucose metabolism vs. fructose metabolism, I have been convinced that this stuff is at least undesirable.
Farming politics and Biochemistry aside, I always find it frustrating that the solution to the unintended consequences of one law is to prescribe more laws. As a physician I am guilty of the same, often using one medicine to counteract the effects of another (breaking Solomon's Law of Pharmacology). Not to excuse my own behavior, but there are very few drugs out there and I have no ability to modify any of them. Stark contrast to our political and regulatory system, which as the ability to modify and improve itself retroactively but chooses to do so only through new prescriptions.
While I applaud my colleagues efforts at applying their skill set to what is a broad and complex problem, I would caution all current and future policy makers to consider the effects of what your predecessors have done before jumping into the dance yourself. Perhaps the next time Health Affairs covers diabetes, they can look back at undoing causes instead of proposing to limit individual freedoms to make up for errors at the policy level.
Sunday, March 11, 2012
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