"Eat better, exercise more" is not a plan
What your doctor didn't have time to tell you about habits
What your doctor didn't have time to tell you about habits
Devon walks into a clinic in Brixton. He is forty-four, Jamaican-born, and has been in London for twenty years. Today his blood pressure is the highest it has ever been. His doctor is kind, the appointment lasts nine minutes, and he leaves with a prescription and three words: eat better, exercise.
He has been leaving with those same three words for six years. He has tried, given up, tried again, and given up again. He has concluded that the problem is him.
The nine minutes are not his doctor's fault. A study of 67 countries found the average GP appointment in the UK runs just over nine minutes, which is shorter than almost anywhere in Europe. Nine minutes is enough to check a blood pressure, write a prescription and say three words. It is not enough to change what happens in a kitchen.
Researchers tracked fifteen years of English GP records, from 2002 to 2017, for people newly diagnosed with high blood pressure or type 2 diabetes. By 2016, 22.7 per cent of new hypertension patients had lifestyle advice recorded. In the same year, 53 per cent were on medication. For type 2 diabetes the gap was narrower and pointed the same way: 40.5 per cent advised, 56.3 per cent medicated.
Both numbers had roughly doubled since 2002, so the direction of travel is right. The distance left to travel is the story.
Researchers interviewed 18 Black African and Black Caribbean adults in the UK who wanted to lose weight, along with 10 people who run weight management services. What they heard was that the advice on offer was built for somebody else. One participant described the standard programme menu as "very much prominently for White people," all baked potato and tuna. Another said she would have more confidence in a dietary coach who was Nigerian, because the person in front of her could not tell her anything useful about her soups or her oils.
The providers agreed. In their own words, there was not much awareness of minority ethnic groups and their traditional foods, and the approaches were "quite western."
Nobody in that study was asking to be told their food was wrong. They were asking how to cook what they already cook, in a way that would not kill them.
There is a harder finding in the same study, and it explains why most of those 18 people had never walked into a weight management service in the first place. The researchers put the absence down to racism in the health system, either met before or expected in advance. A better leaflet does not touch that. Someone who arrives already braced will hear nine minutes and three words as confirmation of exactly what they expected.
In the 1990s a research team ran the same door-to-door blood pressure survey in seven places, using one design and one set of measurements, among populations of West African descent. The results came out as a staircase: hypertension in 14.5 per cent of adults in Nigeria, 15.4 per cent in rural Cameroon, 19.1 per cent in urban Cameroon, 24.0 per cent in Jamaica, 25.9 per cent in St Lucia, 27.2 per cent in Barbados, and 32.6 per cent in a suburb of Chicago.
Read that line again. Same ancestry, seven rates, climbing with every step from a West African village towards an American city. Whatever is doing this, it is not in the blood. It is in the food, the work, the traffic, the hours and the shops.
Twenty years later a different team went back to the question, measuring 2,506 adults across rural Ghana, peri-urban South Africa, Seychelles, urban Jamaica and Chicago. The staircase was still standing. Hypertension ran from 7 per cent among Ghanaian women to 35 per cent among American men. Obesity from 2 per cent among Ghanaian men to 64 per cent among American women. Diabetes from under 1 per cent in Ghana and Jamaica to 13 per cent among American women.
The end point of that staircase is already visible in the Caribbean. In Barbados, 55 per cent of adults aged 40 and over had hypertension, and around 37 per cent of cases were undiagnosed. Type 2 diabetes in UK African and Caribbean communities runs at about three times the rate in white Europeans and arrives roughly ten years earlier.
We did not wake up one morning with somebody else's diseases. These were assembled slowly, in our kitchens and our commutes, over decades. And the standard clinical answer to something assembled over decades is a pill and three words.
Medication keeps Devon alive, and he should keep taking it. What it does not do is change the thing that raised his blood pressure in the first place, so the condition stays, the dose creeps up, and Devon joins the large number of people who have quietly accepted that they will be on tablets forever.
That acceptance is the failure, and it is a failure of the model rather than of anyone's intentions. The system measures whether the right prescription was issued. Nobody measures whether anything in Devon's Tuesday changed.
The DiRECT trial put 46 per cent of people with type 2 diabetes into remission within a year, using a structured weight programme run in ordinary GP practices. Two years on, 36 per cent were still in remission. Type 2 diabetes turns out to be reversible for a great many people, which is not what most patients are told when they are handed their first prescription.
Now look at who was in that trial. Of its 298 participants, 98 per cent were white. Black African participants made up 0.7 per cent, which across the entire trial comes to about two people. South Asian participants, 0.6 per cent. The study that changed what medicine believes about type 2 diabetes was run in 49 practices in Scotland and Tyneside, and it tested the idea on almost nobody who looks like Devon.
The mechanism does travel. DIADEM-I ran a similar intensive programme with participants from the Middle East and North Africa and reached 61 per cent remission at one year, a better result than DiRECT achieved. Effort is what has not travelled.
HEAL-D is what it looks like when somebody makes that effort: a type 2 diabetes programme designed from the start with African and Caribbean communities in the UK, seven group sessions covering food, movement and the practical business of changing a habit. In its online evaluation, 77 per cent of people who started finished, and the share reporting serious diabetes-related distress fell from 49 per cent to 23 per cent. It is now being tested in a full multicentre trial.
So the knowledge exists and the will exists in places. What is missing is scale, and what is missing from the evidence base is African people.
Devon is not the problem. His doctor, working inside nine minutes, is not the problem either. The problem is a model that hands out generic instructions and calls them advice, that counts a consultation successful when the prescription is correct, and that has known for forty years that daily behaviour drives these conditions without ever building a serious way to change it.
Six years of trying in the dark, and blaming himself for not being able to see.
That is what this journal is for.