In Praise of Prevention
Liz Selvin is taking on the slow-burn diseases—chronic illnesses that our health care systems are ill-equipped to handle.
Liz Selvin has a favorite molecule. It’s hemoglobin A1C. The diabetes epidemiologist and Epidemiology professor built her career on the molecule. In fact, she was first author on the 2010 New England Journal of Medicine article that helped establish using hemoglobin A1C to diagnose diabetes. During her more than 20 years with the Welch Center for Epidemiology, Prevention and Clinical Research, Selvin (now its director) has published more than 600 peer-reviewed papers, many of them about diabetes.
“I can talk about diabetes forever,” says Selvin, noting that the chronic disease is an important risk factor for heart disease and has been linked to an increased risk for dementia.
In a wide-ranging interview on Zoom that was only occasionally interrupted by her cat, Dixon, Selvin, PhD ’04, MPH, explained why she’s personally connected to her chronic disease research, what her next major focus will be, and what the real goal for aging should be.
The Slow-Burn Diseases
Infectious disease and acute diseases can command a lot of attention. But chronic diseases like heart disease, cancer and lung disease, dementia, diabetes, they’re the slower-burn diseases. They can get neglected because they don’t have that immediate emergency quality. But these are the leading causes of death, and they’re preventable.
We tend to be very reactive. We’re waiting for things to be on fire. We’re preparing for public health emergencies. We’re worried about global pandemics. But it’s also prevention of chronic disease that is going to ensure the health of our nation.
It’s not a competition at all, but chronic diseases kill way more people than infectious diseases—something like 70% of deaths worldwide are from chronic diseases.
One message that that we’ve not done the best job of conveying is the strong intersection of heart health and brain health. By doing things to improve your heart health, you can prevent not just heart attacks but dementia in later life.
Energy Needed
To really move the needle for chronic disease, we need prevention. A lot of that needs to happen outside the health care system. It’s about systemic issues in society and prevention starting at the earliest ages.
The obesity epidemic is what's driving the major increases in diabetes. Helping people prevent weight gain in the first place is so critical.
Having communities and government come together to make healthier environments with access to healthy food, ensuring that cities have trees and green spaces and people have opportunities for exercise—all these things are critical. But we’re not putting enough energy into them.
The biggest thing that most people don’t really get about chronic disease is most chronic disease is preventable. People can often be very fatalistic, and think that heart disease, diabetes, cancer, stroke are all inevitable, that these are all diseases of aging. But these disease processes are strongly preventable through early intervention and lifestyle changes like diet, exercise, and risk factor control.
Wearable Insights
A lot of my newer work is focused on wearable devices. As a diabetes researcher, I’m very interested in continuous glucose monitors (CGMs). They measure your glucose every minute for up to two weeks, generating vast amounts of data. I’m interested in understanding how well these devices work, how they can improve the lives of people with diabetes, and whether we can use these devices to figure out why some people progress to diabetes and some others don’t.
The other day a colleague told me that he and his wife both bought the new over-the-counter CGMs. He noticed they’re eating the same meals, but his glucose is spiking to 200 mg/dL and hers is not. Does that mean he’s at risk for diabetes? Or is his body reacting differently to the same foods? Or is it just an accuracy issue?
Prediabetes and Older Adults
I led a study—part of Atherosclerosis Risk in Communities (ARIC) research—that had a major impact on how we think about prediabetes in older adults.
Prediabetes had been a common diagnosis for older adults for years. But when we looked at the data, we found that just 8% or 9% of people in their 70s through 90s ended up developing diabetes.
My mom was thrilled when we published this paper in JAMA in 2021, and she read about it in The New York Times. Her doctor had recently told her she had prediabetes. She has a low BMI, exercises every day, and is incredibly healthy. But now she was very worried about getting diabetes. Our research suggested she didn’t have to worry, nor did a lot of her older fit, female friends who had received that diagnosis. She shared the Times story with “The Olds,” as she calls herself and her group of friends.
I was briefly famous amongst her older women friends.
My Father's Dementia
One thing that has been influential for me is that my father has dementia—and my family has a strong history of dementia. My dad has been in a memory care facility since 2022 and was diagnosed with dementia several years before that, but it feels like I haven't had my dad for a long time.
I miss him even though he's still here. That is a really hard part of dementia.
I’ve seen how our health care system is completely ill-equipped to deal with a disease like dementia. The medical system can fail people with chronic diseases, especially in an acute care setting that’s designed to save people's lives who are in front of you, dying. It’s not designed for someone who has a chronic disease like dementia that is extraordinarily complex and many of the primary needs are not “medical.”
The Real Goal
The risk of mortality is 100%. Eventually, we will all die. The real goal is we want people to live to old age and retain physical function, retain their cognitive function, and to be mobile and to be active and to be happy and healthy for the longest period of time.
That’s why focusing on chronic disease is so important.