Thinking About Truth, Obesity, Diabetes and Healthcare

file0002062211258I’m still thinking about truth. As you know, I’m trying to live an integrated life, to be less compartmentalized and follow Jesus as a whole person. Partly, that’s a matter of just doing what I know is right, but, increasingly, I think it’s also a matter of discerning the truth about issues of importance. It’s easy to just go with the flow and internalize the prevailing views without a great deal of thought, and I have probably done too much of that.

In healthcare this issue of, “what is true?” and “how do we know?” is supposed to be settled by evidence. We presume to be operating on the basis of science as we go about diagnosing and treating, and I think mostly that’s true. However doing what’s right typically requires more consideration than just “evaluating the evidence” for what works. Rendering good whole-person healthcare is more complex than it seems on the surface.

I’ve not studied philosophy or epistemology, but here’s how I’m thinking about various categories of truth right now:

  • Revealed truth – Truth as revealed by God through the Scriptures and Jesus, including our reasoning applied to that revelation. This is our Christian worldview, which includes the nature of reality and moral judgments of what’s right and wrong.
  • Empirical truth – What we know or believe based on our experience and evidence. Most of western medicine is based on empirical truth, or at least we want it to be.
  • Definitional truth – Truth that is created by definition. It’s important to highlight this because when definitions change, “definitional truth” changes, but reality does not. In medicine, definitions (for example diagnostic criteria for diabetes) change frequently, and definitional truth is often a basis for action.

In the ordinary course of healthcare, as clinicians and administrators make decisions and take actions, I think we’re usually operating from empirical truth and definitional truth. That’s fine as long as we ensure that those decisions and actions are integrated (or in accordance with) the deeper truth that has been revealed to us. Yet, how often do we take the time to think it through?

Here’s an example (which may be controversial): If the empirical evidence shows that surgical treatment of obesity “works” to bring about weight loss and reduce complications, does that make it the right thing to do? Maybe, maybe not depending on how you answer some other questions. Is obesity caused by a physical defect in the intestine, and surgery sets it right? Is obesity a disease? Or is obesity a behavioral issue that should best be addressed through emotional and spiritual intervention? If the underlying problem is not physical, do we help or harm the patient with surgery? Do we honor God or not when we offer surgery in such cases? For Christians, the ends cannot justify the means.

“Obesity is a disease.” That’s a “true” fact, definitional truth that is. Obesity is a disease only because it has been defined as a disease by the healthcare powers that be. Naming obesity as a disease implies that there is some state malfunction of the body or of the physiology; however, the vast majority of overweight or obese individuals in our society have no causative underlying abnormal physiology. The cause of our obesity epidemic is our habits. If mistreatment of your car causes many mechanical problems, it is not justified to call it a lemon and return it to the dealer.

A recent study suggests that defining obesity as a disease is making our national problem worse. No surprise here, truth matters. But like we discussed in the last post, the truth hurts and we don’t always want to hear it. When we avoid the hard truth, we feel better in the short run but do ourselves little good.

Now diabetes is certainly a disease, and type II diabetes is often secondary to obesity. One of the best and first line treatments for diabetes is metformin. That’s the empirical truth. It’s also empirically true that weight loss may benefit diabetes more than metformin (depending on the bodyweight, not all type II diabetes is secondary to obesity).   Both are true, but the latter is a more “upstream” truth about diabetes than the former. It would be best for most patients to lose weight, than to remain overweight and be treated with metformin.

For integrated, whole-person care we need to understand the whole truth, we need all of the facts, and, importantly, we need to understand their proper order. The deeper, more upstream truths about how humans are created are the more powerful. How do we in healthcare operate from those truths more, and from the downstream truth of “there’s a pill for that” less? I don’t have the answers, and many will say, “but most patients simply don’t lose weight.” Yes, but still we must not lose focus on the deeper answers we have for them.

A definitional truth that particularly bothers me is “type II diabetes is incurable.” That’s another one that I don’t think is helping us. According to medical orthodoxy, if a diabetic person’s blood sugars return to normal limits after weight loss and off medication, that individual still has diabetes that is “diet controlled.” Makes no sense to me, but the argument is that the individual has proven a propensity (or genetic predisposition) for diabetes and that it may return someday so we should still label them with the diagnosis.

Hmm…

Try this thought experiment: Bob, age 25, is a fit, healthy, 155 lb. movie actor who wins a new role that calls for him to become obese. His blood sugars have always been well within normal limits. But after gaining over 100 lbs for the role, when Bob sees his doctor in middle of shooting he has a fasting blood glucose of 140mg/dL. Bummer – Bob now has diabetes. After discussion with his doctor, Bob decides on no therapy because the movie is about wrapped up and he plans to lose weight promptly. Within 5 months, Bob’s back to his baseline weight and his fasting blood sugar is 90mg/dL.   According the healthcare system, Bob still has diabetes. Does that sound right to you?

Sure, Bob might get high blood sugar again later in life, especially if he gains weight. But does that mean he has diabetes now? Is it helpful to tell him he still has diabetes? It is true, really? What if Bob, had an identical twin (exactly the same genetics) named Mark. Should we diagnose Mark with diabetes based on Bob’s experience?   It would be logical to do so based on the definitional truth. (Imagine Mark’s surprise when we tell him!) On a practical basis, is it helpful to tell the average obese person with type II diabetes that his obesity is a disease and that his diabetes is incurable?

We don’t do that with other conditions. Grief is one my family is familiar with lately. People expereince grief after a close friend or relative dies. Gradually they work through it until it’s resolved. We don’t continue to say that they have, “thought controlled” grief or “quiescent” grief or “latent” grief. No, we say that it’s “resolved” or gone even as we know they may likely experience grief again in the future. Imagine if we told every grieving person that his or her grief was “incurable” and the best we could do was “control” it. That is the orthodoxy is with type II diabetes.

Mostly, I don’t think we are doing ourselves any favors by creating more and more “diseases.” Much of our problem is our behavior and our thinking. Many of our social problems, and our national ill health, arise from our culture. We don’t help ourselves by sweeping the hard truths under the carpet in favor of easier “truths” – classifying our problems as diseases and seeking a solution from healthcare.

Don’t think I’m against healthcare. We have amazing abilities in healthcare today, and people do suffer from many ills for which we now have effective treatments and cures. Praise God! I’m not against healthcare; rather I’m for health! And sometimes the facts you need on the road to truly good health are not the facts you get from the healthcare system. I don’t claim to have the answers, but I feel that questions such as I’ve outlined here can lead us in the right direction.

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Always beware of any assessment of life which does not recognize the fact that there is sin. Oswald Chambers

Comments

  1. This timely article addresses “truth” at a historical level: https://stream.org/gmarriage-worse-think/