Diabetes, Obesity, and the Ambulance in the Valley

In all of the work we do with nutrition, obesity, and metabolic health, nothing is more irritating than a false choice between prevention and treatment. More than a century old, the parable of The Ambulance Down in the Valley is a perfect expression of it. Shall we spend all of our money on an ambulance at the bottom of a cliff to carry people away when they fall? Or instead spend money on a fence to keep people from falling? It’s a good metaphor. But when applied to diabetes and obesity, is obesity care supposed to be the ambulance? Or the fence?

Too often, policy wonks and policy makers assign the role of the ambulance to obesity care.

Preventing Ten Years of Poor Health

Recently Lancet published 10-year outcomes for metabolic surgery. After ten years, the results were compelling. Health was unmistakably better for patients who got the surgery. Patients were healthier. Their diabetes was either in remission or in better control. Adverse events were fewer for surgery patients than they were for patients receiving only medical care for diabetes in this RCT. This sure seems like the prevention of poor health.

Yet it strains the brains of most people to think of surgery as prevention. So when someone trots out the ambulance parable, this form of obesity treatment gets the role of the ambulance. At a recent workshop of the Roundtable on Obesity Solutions, one speaker went so far as to talk about “greedy bariatric surgeons.”

We Refuse to Choose

Here’s the nub of the issue. It’s not OK to tell people with obesity that their problem was preventable and then systematically deny access to care. For starters, it’s wrong because with 43 percent of the population having obesity, reality tells us obesity has not been very “preventable” for the last four decades. It has only only grown in prevalence.

But it’s also wrong because good obesity care is prevention. Managing the complex, chronic disease of obesity means preventing diabetes, liver disease, heart disease, and even cancer.

Addressing Social Determinants of Health

Yes, we must address social determinants of health. Social and economic disparities contribute to disparate burdens from chronic disease, including obesity. Reducing those disparities is imperative. But the cost for doing so cannot be denying people access to medical care they need. Racism is killing people and making them sick. Telling people who are suffering now that they must wait while we go and work on the social determinants of health is simply unacceptable. Unconscionable.

We can walk and chew gum at the same time. We can end racism and provide better access to care – including competent care for obesity.

Click here for the study of surgery in Lancet and here for further perspective. For further perspective on the intersection of obesity, racism, and health disparities, click here. For perspective on how better access to care can bring better health, this analysis from the Kaiser Family Foundation is helpful. Finally, this paper applies the ambulance parable to social determinants of health.

Flutist on the Cliffs, painting by Paul Gauguin / WikiArt

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April 13, 2021