Looking Upstream

For many, the phrase “looking upstream” is a familiar term related to preventive health care. It was used by John McKinlay in an address to the American Heart Association in 1974¹ to describe his frustration with medical practice. He used the analogy of a rapidly flowing river to represent illness and said that physicians are so caught up in constantly rescuing victims from the river that they have no time to look upstream to see who is pushing their patients into the water. He further discussed frustration with what he termed the “downstream endeavors,” which he characterized as short-term, problem-specific, individual-based interventions, and challenged health professionals to refocus and look upstream, where the real problems lie.

I would like to share some thoughts I have about upstream thinking in terms of diabetes and diabetes educators.

Diabetes Education and Downstream Endeavors

When I think of the downstream endeavors of diabetes educators, I do not look at them as a negative because we do rescue people, often from lack of education about self-care, or from fear. We provide hope and a means for improved health through self-management and empowerment. We also help people with diabetes understand their disease, teach them what they need to do to manage it, and motivate them to follow treatment regimens. And, we are present to listen to concerns and offer support. Diabetes educators make a difference in people's lives.

We also carry out upstream endeavors, through secondary prevention. We help prevent people from falling into the river that flows toward diabetes complications and heart disease. We do this by ensuring that people get their screening examinations and helping them control their diabetes, blood pressure, and lipids. Recently, our role as diabetes educators has expanded as the diabetes community has begun to look upstream to diabetes prevention. We know from the Diabetes …