The U.S. has a growing epidemic of obesity, diabetes, and cardiovascular disease. A full 45% of adults are pre-diabetic or diabetic — up from 25 percent 25 years ago. Medicine calls the progression it’s following an ‘epidemic.’ Why would a noncontagious disease like diabetes follow an epidemic curve? One of the main reasons comes down to the fact that our identity equates to our web of social relationships. Cultural attitudes toward diet and exercise spread through this web like a virus. Medicine, unfortunately, doesn’t know how to work with this kind of systemic change.

A hundred years of fighting microbes have taught medicine to focus on single causes with pinpoint cures. The reductionist approach fails us: The epidemic demands a network approach. This may mean something counterintuitive: fighting an epidemic with another epidemic — designing for emergent behavior. Pushing the system to behave in a different way by making small interventions enabled by technology.

This may mean something counterintuitive: fighting an epidemic with another epidemic — designing for emergent behavior.

Diabetes’ distinctive feature involves its slow progression spanning decades. A good way to conceive of it starts with understanding how our network of organs transports, burns, and stores energy from food. A brief tour of how that network (slowly) goes out of whack:

• The network ‘communicates’ through chemical signals sent via our bloodstream. Each organ plays a different role. The liver converts glucose to fat when we have too much of that ‘quick’ energy to burn.
• It sends the fat out through a transport vehicle called HDL, or ‘good cholesterol’ to be stored in fat cells. Once too much fat reaches the cell, though, the fat cell resists its absorption. It gets sent back to the liver using LDL, or ‘bad cholesterol.’
• The liver needs the help of a ‘bouncer’ to chemically knock on the fat cell’s door and get it to open. That ‘bouncer’ is insulin, which is produced by the pancreas. The more fat the liver sends out, the more the fat cell resists, and the more insulin is needed.
• As this fat ‘tug of war’ between the liver and fat cells continues, a cascade of linked reactions causes inflammation in the body that might lead to cardiovascular disease, liver problems, and other symptoms. The production of cortisol, the stress hormone, also exacerbates these conditions. Not surprisingly, all that fat storage often presents as obesity, and so the obesity and diabetes epidemics are linked.
• Ultimately, the pancreas gets overworked from producing all this insulin, and it starts to shut down. This very last part, characterized by patients needing help replacing low insulin with daily injections of a synthetic form, we call diabetes.

Unfortunately, the pre-diabetic metabolic changes (syndrome x, or metabolic syndrome) described above might go unnoticed by doctors. Even when detected, they diagnose it as ‘pre-diabetes,’ ‘syndrome x,’ or ‘metabolic syndrome.’ No matter the name, it typically receives very little holistic, cohesive, or sustained attention.

The conventional medical community debates whether or not metabolic syndrome even qualifies as a stand-alone diagnosis, as opposed to a signpost on the road to the inevitable diabetes destination. Doctors’ ubiquitous awareness of the diabetes epidemic stands in stark contrast to their lack of confidence and motivation to combat it. The prevailing mantra in the conventional medical community involves the obese patient ‘taking personal responsibility’ for their weight and blood sugar problems. Someone somewhere along the way labeled overeating and lack of exercise the cause of the problem. The underlying assumption? The individual must rectify these moral failings, or else the medical community waits to provide pharmaceuticals and/or surgery. Professional support is reactive, fragmented, impersonal and time-limited.

Doctors lack confidence in their ability to change patient behavior as well as the tools to do so. One reason involves the adverse metabolic progression’s social nature. The more refined carbohydrates and sugar our friends consume, the more we eat. Our own obesity and our friends’ attitudes toward their weight relate to one another. Of course, patients get barraged with advertising tempting them to eat sugar-laden foods, and the government hardly helps. Its nutrition standards advise against eating fat — a green light to consume carbohydrates.

A doctor presented with a pre-diabetic patient battles all of these network dynamics. Understandably, doctors might send a patient off with ‘diet and exercise’ advice, knowing full well the patient’s disease may progress. The financial expense to the U.S. government and private businesses overlays the tragic human cost. No other disease costs the U.S. as much as diabetes and cardiovascular disease combined. This runaway train shows few signs of slowing down.* The reductionist and impersonal medication- and surgery-based approach failed, but a time for new approaches has arrived.

Any approach must recognize both the social nature of the disease and doctors’ difficulty in addressing it — rather than watch it progress. Doctors need tools offering them leverage over patients’ social behavior without taking too much of a doctor’s scarcest commodity: time. These tools exist. One mirrors and harnesses a social dynamic spreading like an epidemic. The other is an app. Together, they allow a systems approach to stopping or even reversing the progression toward diabetes.

The multibillion dollar phenomenon of fantasy football holds an answer. In the U.S. alone, the Fantasy Sports Trade Association estimated that 32 million Americans spend approximately $500 a year on fantasy sports with 80%+ flowing specifically into football. This represents an ‘installed base’ of adults excited about the prospect of wellness ‘gamification’ along similar lines. Many of these adults, of course, suffer from metabolic syndrome…trodding toward diabetes.

The key is strong momentum to overcome the inertia represented by social attitudes toward diet and wellness.

This sets up an opportunity for doctors to leverage this new social gaming technology. By developing ‘Fantasy Fitness’ leagues, they can engage people in a fun and exciting distraction while they develop and maintain healthy lifestyle changes. The key is strong momentum to overcome the inertia represented by social attitudes toward diet and wellness. The ‘fantasy’ epidemic provides such momentum. ‘Fantasy Fitness’ leagues harness the natural power of competition and social connection, supplying an ideal vehicle for addressing some of the major health problems currently facing the U.S. ‘Lifestyle’ diseases, including cardiovascular disease, stroke, obesity, diabetes, and all the diseases associated with smoking, alcohol, and drug abuse.

The vehicle for ‘Fantasy Fitness’ is an app currently under development. The ideal fantasy football season is approximately 10 weeks. This fits with research showing it takes 66 days on average to make a new habit, like a change in diet. Unlike the vast majority of apps out there, designers intended the fantasy fitness app to be mediated by a doctor. The physician helps players set personalized goals prior to the ‘season’ that underpin the journey toward a healthier mental and physical state. These goals involve reversing the physical markers of metabolic progression toward diabetes. A doctor’s involvement allows the competition to actually target things like blood lab scores. It’s a far cry from competing on the most ‘steps,’ a worthy goal, but not a way to directly address the metabolic problem at its root.

Once the season is underway, the same doctor provides wellness coaching in an effort to help the players get the most from their will to win the competition. Ideally the league includes players/teams familiar with one another on a personal level as familiarity enhances competition. The best competitions would occur between employees of the same company, or similar types of employees across companies (i.e., upper management). Daily tracking, weekly winners, and passive collection of pertinent data via wearable devices will enhance adherence and engagement. More important, it would provide data on what works and doesn’t to a doctor that will get better and better at coaching the teams. This type of specialization is hard to achieve in wellness medicine, since it occurs outside the doctors’ offices. The initial target illness is metabolic syndrome, but the concept can be applied to a multitude of other lifestyle-related illnesses and concomitant behavioral changes.

Technology and fantasy football-like competition can bridge the gap between the doctor and the patient’s behavior within their social circle. This is the key. It’s time to realize it takes something like a ‘social epidemic’ to fight the biggest threat to our health: a social epidemic that happens to cost us hundreds of billions of dollars a year.

* The CDC reports five straight years of decline in new rates of disease, although doctors have diagnosed many millions of new cases in that time.

REFERENCES

Shute, N. (1 Dec., 2015). Fewer People Are Getting Diabetes, But The Epidemic Isn’t Over. NPR [Radio report]. Retrieved from the Web.