In this issue of Diabetes Care, the American Diabetes Association (ADA) together with the American Heart Association (AHA) and American Cancer Society (ACS) jointly review the scientific evidence supporting the efficacy of preventive measures in decreasing the incidence of, and morbidity associated with, cardiovascular disease, cancer, and diabetes (1). One rationale behind this joint initiative by the three organizations is to highlight the importance of common preventive efforts with demonstrated efficacy. More than that, this joint publication is a clarion call that signals a new era of joined efforts by volunteers and staff in these organizations to place an appropriate emphasis on the enormous health benefits gained by smoking cessation, regular exercise, and judicious food selection.
It is reasonable to ask “Why now?” Why have these organizations (which have in the past cooperated/collaborated only intermittently and typically around more narrow, specific issues) now come together with a common purpose and a resolve to have a more enduring collaboration built around a shared comprehensive vision? The question is presented even more strongly as these organizations have often competed in the “Philanthropic Marketplace,” a phenomenon that will surely continue. Almost certainly, the answer lies in a shared recognition that each organization can move forward most effectively to meeting their respective missions by sharing efforts in education, advocacy, information, and research to provide a greater good for the people they serve.
We’re reminded of the familiar story of the “Tragedy of the Common.” In that paradigm, the shared grazing ground or “Common” in the traditional country village suffered when each member of the community felt they could successfully add one or two more sheep. Finally, the grazing land simply played out and the Common, which had previously served the good for all, served no one. In this case, the “Common” is not a field but the health environment of our nation. Many factors have been added to the environment that at first may seem innocuous or beneficial, but in the long run may also be deleterious. Examples of this include the growing availability of high-caloric foods that are increasingly inexpensive, the abundant use of cheaply made corn products (e.g., high-fructose corn syrup) that have uncertain metabolic consequences, ever-increasing mechanization of our industries that require less human activity per unit of productivity, virtually unlimited access to automobiles and an increasing network of roads and highways that also reduce physical activity, and the growing popularity of electronically delivered entertainment (e.g., computers) that requires no physical exertion. Each (like the additional sheep) in itself is a seemingly good thing. However, in aggregate, each has contributed to a change in the health environment in the U.S. (and in other developed and developing countries) that favors obesity, a sedentary lifestyle, and with that, an increased risk for cardiovascular disease, cancer, and diabetes.
Obviously, it is not practical or even desirable to reverse these advances of our modern world, but how then do we protect the “Common,” i.e., our health environment? Without being too simplistic, a first step is to recognize the impact that our changed environment has already had, then to prospectively begin to take measures that can positively impact our adaptation to the environment in a manner that promotes health and prevents disease. This alone is no small task. Here is where the importance of the joint effort becomes particularly crucial. Each organization has both a constituency and credibility with the American public. Combined, synergism would be anticipated. Speaking with a single voice, the potential to impact economic, legislative, and informational agendas is enormous. One could only imagine that the national effort to eliminate cigarette smoking from all public places (if not cigarette smoking altogether) would have met with even more rapid acceptance had our three organizations unified behind this concept and, through advocacy and informational activities, driven this process forward.
The same is true for the epidemic of obesity that has begun to consume the country and its resources. There are already signs that the food industry is becoming more responsive and interested in participating in efforts to provide healthier eating choices at acceptable prices. Much more needs to be done. The combined efforts of the ADA, ACS, and AHA will play a major role in this arena. Gratefully, our federal health leadership, particularly those in the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, and the National Institutes of Health, have provided leadership, energy, and insight in the national response to the obesity epidemic. There has been a strong, unified response from the voluntary health organization leadership. This new organizational sector will certainly enhance their efforts.
Each of these three organizations embraces as their mission a panoply of responsibilities that contribute to improving the nation’s health. Many of these are specific to each organization and will continue to need and receive major attention by each organization. It seems particularly appropriate that the joint efforts of the AHA/ADA/ACS center on the issue of prevention. It is here that there is the most common ground. This common ground is rooted in the recognition of shared biological processes that drive increased risks for cardiovascular disease, cancer, and diabetes. This common ground includes a nutritional, hormonal, and metabolic environment typically seen in individuals with type 2 diabetes or with the insulin resistance syndrome (e.g., obesity [particularly central obesity, high triglycerides, and low HDL cholesterol], hypertension, and polycystic ovarian disease). The association of these problems with both diabetes and premature cardiovascular disease is well established. The association of obesity with various forms of cancer is being increasingly appreciated. It is also particularly appropriate that prevention be a common point of emphasis for the three organizations in as much as preventive health measures have received less attention on the national health scene than have direct therapeutic interventions for established diseases. This is perhaps best illustrated by the observation that <10%, and perhaps as low as 5%, of health care expenditures are for preventive measures. In addition, some of the outstanding successes that have been made in health promotion lie in the area of education about disease prevention for heart disease, cancer, and diabetes. Thus, campaigns focusing on messages for the general public to decrease smoking and to be aware of and control cholesterol and other cardiovascular risk factors have lowered rates for both cardiovascular disease and cancer. In addition, educational approaches have been targeted to support and enhance earlier recognition and emphasis on behavior change, by our medical teams and health professionals who serve these communities. Likewise, we hope that recognition of the beneficial effect of weight reduction and exercise will impact the incidence diabetes, heart disease, and cancer.
The joined energy, expertise, and commitment of these organizations provide a sign of hope for the future health of Americans. We at the ADA look forward to working with our colleagues at the AHA and ACS on the many facets of this prevention initiative. We anticipate that our organizations will soon see the fruit of our collective action and even recognize additional areas where our joint efforts will provide added value, thereby halting the decline in the Common and restoring the promise of health for all.
