To: Ashwin Vasan, MD, PhD- NYC Department of Health and Mental Hygiene Commissioner 

From: Malka Einhorn

Date: July 23, 2023

Re: Increasing numbers of type 2 diabetes mellitus in younger individuals

Statement of Issue

What proactive policy can be implemented to effectively reduce the prevalence of type 2 diabetes mellitus (DM) and curb the concerning trend of its diagnosis in younger individuals?

Background

Of the 37 million Americans who are currently diagnosed with diabetes, 90-95% have type two diabetes¹. This disease was commonly prevalent in adults, however in more recent years it is becoming more common in children and teens. According to the CDC, the amount of children aged 10-19 who have been diagnosed with type 2 DM has increased from 34 per 100,000 in 2001 to 67 per 100,000 in 2017². This provides a major public health concern as type 2 DM is known to have many complications which include heart and blood vessel disease, nerve damage, kidney disease and more³. If the age of diagnosis continues to decline even further, it poses the threat of increased numbers of individuals diagnosed with the above complications, leading to an even unhealthier society and hiking up healthcare expenses even more.

There is much research dedicated towards understanding the role of diet of the American people which may be contributing to this ever-growing issue. There are many research articles which point towards fast food, processed foods and sugary beverages as a major source of the growing risk and development of type 2 diabetes. Research utilizing meta-analysis found a positive correlation between sugar sweetened beverages (SSB) and type 2 DM, suggesting that with each 250 mL increase in consumption of a SSB the risk for T2D is increased. Some explanations for why this may be the case include its high glycemic load, and its association with obesity. Additionally, the fructose enhances hepatic lipogenesis and insulin resistance⁴. On the other hand, whole grains were noted to have a strong inverse relationship with T2D and vegetables have a minor inverse relationship with T2D⁴. The fact that fast food and processed foods are so accessible in the United States only makes it harder to choose to eat healthy. Many times people do not cook due to a lack of confidence in their cooking, lack of time, and lack of convenience. By allowing fast food to be such an easy option it puts many Americans at a greater risk for developing type 2 diabetes in their lifetime and poses a great public health concern.

Landscape

When devising and implementing a policy to address this public health concern, it is essential to consider various stakeholders who will be involved in passing, implementing, and enforcing the measures. This policy’s success hinges on collaborative efforts from several key groups. One measure that can be taken to curb the increasing numbers of T2D is to implement a tax on unhealthy foods, and a multi-faceted approach is required to do so. Firstly, the support and cooperation of the House of Representatives, Congress, and the POTUS are crucial for passing the federal tax legislation. Additionally, it is imperative to partner with the fast food industries directly impacted by the tax, as they play a significant role in the public’s food choices. Furthermore, involving grocery stores and markets is essential since they also sell products subject to the proposed tax. Drawing on the expertise and influence of renowned chefs could prove invaluable in inspiring individuals to cook and have confidence in their culinary abilities. It is also crucial to educate young individuals about the risks of Type 2 DM, and collaboration with the education sector becomes paramount in achieving this goal. It is vital to gain the support and commitment of the Department of Education, school principals, and teachers to successfully integrate educational initiatives into the curriculum.

Policy Options

• A potential policy option in accomplishing this goal is to create federal mandates and efforts towards increasing the price of fast food and junk food or adding taxes on these foods. Just as important would be to decrease the price of whole grain groceries and vegetables to ensure that it is available to the common American. A full meal in McDonalds consisting of a McDouble, large fries and large soda costs less than ten dollars, easily adding up to 1,180 calories and 81 grams of added sugars in one meal⁶. To put that into perspective, that is about 24 teaspoons of sugar, where the daily limit of added sugar consumption is about 12 teaspoons for a 2,000 calorie diet⁷. On the other hand, buying chicken, brown rice and vegetables to make a salad at home can easily amount to well above ten dollars. Therefore, even if people are willing to spend the time to make their own food at home, many people struggle with the price of healthier options, which forces them to resort to fast food. This is a concerning issue because in 2021 the poverty rate was 11.9%, with 37.9 million people living in poverty⁸.
  • Advantages: Decreasing the price of healthier meal alternatives will make these foods available to a larger portion of society, allowing healthier options to people living in poverty. Taxes on unhealthy food will also succeed in deterring people from buying them. To evaluate the prospective effectiveness of this mandate, we can compare it to similar mandates that have been implemented for SSB. In 2014, Mexico instituted a 10% tax on SSB which resulted in a 7.6% decrease in sales of SSB and a 2.1% increase in sales of untaxed beverages, such as water, 2 years later⁹. If we apply this to a broader group of fast food to be taxed, and healthier options to be free of taxes, we should expect to see similar trends.
  • Disadvantages: Sugar has been linked with addictive behaviors, as it releases endogenous opioids which explains increasing consumption of SSB and even withdrawal symptoms⁹. Though findings of this fact are inconsistent among humans, this may provide a challenge with taxing SSB and may decrease the effectiveness. As seen with other addictions, people are willing to spend money, no matter how much, to sustain their addiction. Therefore, people who may not necessarily be able to afford it, and even more so people who can afford increasing costs of fast food, may continue to buy the foods that they are addicted to. Another disadvantage that cannot be dismissed would be the loss of business to all fast food places leaving many people unemployed, which may further exacerbate the poverty levels of America and may have severe negative effects on the economy.

• The complications that diabetes poses to a person’s life is extensive. Even simple things that are taken for granted, such as wound healing, is often impaired in a person who has T2D. The extent of such concerns are not fully understood by all American citizens. This lack of understanding lends itself to people making poor lifestyle decisions in regards to diet and exercise. In other words, due to the fact that people don’t know all that the disease can do to their life they may not try with all their power to prevent themselves from getting the disease. Therefore, a federal mandate can be put in place which makes it mandatory to teach students from as young as elementary and middle school age the concerns and complications of obesity and T2D in an attempt to make the general public aware of these risks. The premise of this proposed idea is supported in the fact that people with less than a high school diploma were 3.2 times more likely to develop DM than others with a bachelor’s degree¹⁰.
  • Advantages: By making children aware of the consequences of the illness, it will likely instill a desire to prevent themselves from getting T2D to begin with. Educating the children will give them the knowledge that they need in order to make the decision on their own to exercise and restrain from eating fast food and other unhealthy foods. This is beneficial because when people make a choice on their own, based on information that they know, those choices are more likely to stick throughout a lifetime¹¹. Additionally, educating young children very early on about the risks associated with sugar addiction would potentially be able to prevent this addiction from ever occurring. Additionally, the cost of this option is very low, as teachers already are employed and will only need to choose to include this crucial subject matter into their classes.
  • Disadvantages: There are two things that must be considered with this policy. The first is that, at least in the beginning, it leaves much of the population that are no longer in public schools vulnerable to T2D. This poses the risk of parents who were never educated on the dangers of T2D continuing to feed their young children fast food and SSB which will keep their children at risk of sugar addiction. Until the children of the generation where this education is implemented become adults and parents, this risk stays relevant. The second issue that must be considered is the timing of the school day and the practicality of this option. Within the school day there are many subjects that must be taught and cannot be cut out of the curriculum. This leaves a challenge of how to add another required subject into the day, resulting in longer school days or shorter breaks between classes.

• In an article written regarding fast food and its implications on life it is suggested that one of the reasons so many people resort to consuming fast food is because they lack confidence in their cooking capabilities. Therefore, they suggest that limiting access to fast food may not be the sole solution to this public healthcare crisis⁵. One solution to fix the particular problem may be to aim to increase the self confidence that people have in their ability to cook. This can be done by providing easy to follow recipe pamphlets, with linked videos, in doctors offices and grocery stores.
  • Advantages: By providing such pamphlets, it will instill the confidence in people that they can in fact cook delicious food that is also healthy. This will aim at healing an intrinsic issue which influences many lifestyle choices that people make. By focusing on the root cause, this solution will provide longer lasting benefits as opposed to a solution that will fix the outer layer of the problem, and only serve as a temporary bandage.
  • Disadvantages: The main concern with this idea is that many people often walk right past such pamphlets and the pamphlets never make it into people’s homes. An idea would need to be considered in order to ensure that people would actually take the pamphlet and read it. Another disadvantage is that this would not deal with the concern that many people don’t make home cooked foods due to time restraints. Therefore, the recipes provided would need to be easy enough that they would not take too much time, in order to ensure that the issue of time constraint is minimized as much as possible.

Policy Recommendation

In order to truly fix the deeply concerning issue of increased numbers of T2D it is important to address the problem internally. This issue cannot be fixed forever with a “simple fix,” but rather with something that will change the mindset of the nation. Therefore, I propose that we choose option two and begin the necessary training and planning to begin to teach young students about the effects of DM 2. Although parents may not gain the same knowledge that the children are getting, we can try to alleviate that issue by sending home pamphlets and making parent nights to educate them on the topic. Additionally, by teaching the children we are setting up the next generation for success instead of perpetuating this mounting problem. In addition, this option is better than the other two suggested reforms because this, as opposed to the other two, aims at fixing the issue at its core and changing the desires of the public. This, rather than either forcing people to eat healthier due to financial factors or even trying to fix one of the smaller causes of fast food consumption, will eventually cause people to refrain from fast food consumption from their own desire which intrinsically will last longer. With knowledge comes power, and in this case willpower to stay away from fast food and maintain their health.

Works Cited

1. CDC. Type 2 Diabetes. Centers for Disease Control and Prevention. Published May 30, 2019. https://www.cdc.gov/diabetes/basics/type2.html#:~:text=Healthy%20eating%20is%20your%20recipe

2. CDC. CDC Newsroom. CDC. Published August 24, 2021. https://www.cdc.gov/media/releases/2021/p0824-youth-diabetes.html

3. Mayo Clinic. Type 2 Diabetes. Mayo Clinic. Published March 14, 2023. https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193

4. Schwingshackl L, Hoffmann G, Lampousi AM, et al. Food groups and risk of type 2 diabetes mellitus: a systematic review and meta-analysis of prospective studies. Eur J Epidemiol. 2017;32(5):363-375. doi:10.1007/s10654-017-0246-y

5. Fulkerson JA. Fast food in the diet: Implications and solutions for families. Physiol Behav. 2018;193(Pt B):252-256. doi:10.1016/j.physbeh.2018.04.005

6. $1 $2 $3 Dollar Menu | McDonald’s. Mcdonalds.com. Published 2011. https://www.mcdonalds.com/us/en-us/full-menu/123dollarmenu.html

7. CDC. Know Your Limit for Added Sugars. Centers for Disease Control and Prevention. Published November 28, 2021. https://www.cdc.gov/nutrition/data-statistics/added-sugars.html#:~:text=Americans%20should%20limit%20their%20added%20sugars&text=Americans%202%20years%20and%20older

8. United States Census Bureau. National poverty in America awareness month: January 2022. Census.gov. Published January 2023. https://www.census.gov/newsroom/stories/poverty-awareness-month.html

9. Malik VS, Hu FB. The role of sugar-sweetened beverages in the global epidemics of obesity and chronic diseases. Nat Rev Endocrinol. 2022;18(4):205-218. doi:10.1038/s41574-021-00627-6

10. Borrell LN, Dallo FJ, White K. Education and diabetes in a racially and ethnically diverse population. Am J Public Health. 2006;96(9):1637-1642. doi:10.2105/AJPH.2005.072884

11. Ryan RM, Deci EL. Intrinsic and Extrinsic motivations: Classic Definitions and New Directions. Contemporary Educational Psychology. 2000;25(1):54-67. doi:https://doi.org/10.1006/ceps.1999.1020