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Diabetes is nearing epidemic proportions in the United States due to an increased number of older Americans and a greater prevalence of obesity and sedentary lifestyles among Americans of all ages. The Centers for Disease Control and Prevention (CDC) estimates that 16 million Americans have diabetes. Rates are highest among people of African-American, Hispanic/Latino American and Native American descent.
Lifestyle changes to risk factors such as diet and physical activity can improve outcomes for patients of all ages with type 2 diabetes, which is the most prevalent form of the disease. Yet little has been known about how often doctors provide lifestyle counseling or referrals to address these risk factors.
To find out whether lifestyle counseling and referral were associated with race, researchers at the University of Chicago examined data from the 2002-04 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Of the 6,800 visits in the study sample, 69 percent were made by whites and 26 percent by African-Americans.
Researchers found that, rather than being distinguishable along racial lines, only a small number of patients in either group received lifestyle modification counseling or referral to a counselor.
The study appeared in the November 2008 issue of the Journal of General Internal Medicine.
Diabetes occurs when the body can’t turn blood sugar, or glucose, into energy, either because it doesn’t make enough insulin – the hormone produced in the pancreas that metabolizes glucose – or because it doesn’t use insulin correctly.
In type 1 diabetes, the immune system attacks the insulin producing cells in the pancreas, creating an insulin deficiency that requires a life-long regimen of insulin administration. Type 2 diabetes is a disease of insulin resistance. The body produces insulin, but it isn’t sufficient because it’s not being used properly.
Lifestyle changes can improve outcomes for patients of all ages with type 2 diabetes.
Lifestyle changes can improve outcomes for patients of all ages with type 2 diabetes.
Type 2 diabetes occurs most commonly in people over age 45; although in recent years more adolescents and teenagers have been diagnosed with the disease. Symptoms may be mild or go unnoticed for a long time.
Some of the more common symptoms of diabetes are:
• frequent infections that are not easily healed. • high levels of sugar in the blood when tested. • high levels of sugar in the urine when tested. • unusual thirst. • frequent urination. • extreme hunger accompanied by loss of weight. • blurred vision. • nausea and vomiting. • extreme weakness and fatigue. • irritability and mood changes. • dry, itchy skin. • tingling or loss of feeling in the hands or feet.
Untreated or inappropriately treated diabetes can cause problems with the kidneys, legs, feet, eyes, heart, nerves and blood flow, which could lead to kidney failure, gangrene, amputation, blindness or stroke. For these reasons, it is important for patients to follow a strict treatment plan.
A 2001 report from the U.S. Surgeon General drew national attention to the need for lifestyle modifications to reduce obesity and obesity-related diseases such as diabetes. However, the Chicago study found there has been little improvement, since the report was published, in nutrition and exercise counseling rates. Both white and black patients were counseled about nutrition by their physician or referred to counselors only 37 percent of the time, according to their findings. The rate of exercise advice or referral was 19 percent.
The researchers did find certain predictors of counseling or referral. Those most likely to receive counseling or referral had private insurance, an increased number of co-morbid illnesses or were younger on average. Patients were also more likely to receive nutrition and exercise interventions if they were seen by a primary care physician.
“Given the potential benefit from lifestyle modification,” the study’s authors wrote, “and evidence supporting the efficacy of primary care-based interventions, there is a need to identify mechanisms to enhance the delivery of nutrition/exercise counseling to patients with diabetes in the outpatient setting.”
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Diabetes can’t be cured, but it can be controlled with early education. The Chicago study raises awareness significantly that more people with diabetes should be receiving lifestyle counseling.
“After a year of enrollment [in DiabetesCARE], patients had significant decreases in blood glucose and cholesterol levels.”
Kentucky has one of the highest rates of diabetes prevalence in the country; 9.9 percent of the population has the disease. Nationwide, that rate is 8.1 percent. Many Kentuckians are putting themselves at risk for diabetes by not exercising or controlling their weight. According to the CDC, the state ranks ninth in the nation for obesity prevalence. In addition, Kentucky has the fourth highest percentage in the nation of adults who do not participate in any physical activity.
Diabetes can be very silent early on. Often, when blood sugar is just above the threshold, a patient may not feel any different. But with early education, diabetics can get their disease under control and are less likely to have complications. Just by dropping one percentage point of a1C (average blood sugar level over a period of two to three months), a patient lowers his or her risk of complications by 35 percent.
One reason many patients with diabetes aren’t getting counseling and education is that the doctors often just don’t have enough time. Another is that some doctors may not think education is really necessary until the patient is in advanced stages of diabetes. Additionally, patient apathy can be a factor. Health care professionals need to be more innovative in reaching patients.
One way we are educating patients at UK HealthCare is through a program called DiabetesCARE, an American Diabetes Association-recognized program of diabetes self-management. It is a pharmacist-provided management service.
Pharmacists act as facilitators and educators. With the ADA designation, they are allowed to bill Medicare and all major insurance companies for services.
We offer three group-education classes during the evenings at Kentucky Clinic South. At the end of the third class, we work with the patients to help them set behavioral goals, such as walking two to three times a week and choosing low-carb snacks.
For many patients, the classes are a form of accountability. We go over their medications with them, which is important because it’s not uncommon for patients with type 2 diabetes to have six or eight medications. We also employ a dietitian to help with the counseling.
A 2003-06 study we conducted of 236 patients at UK showed that the DiabetesCARE program is successful in enhancing health outcomes for diabetics. After one year of enrollment, patients had significant decreases in blood glucose and cholesterol levels.
Diabetes is more prevalent in the Western cultures, where we’re prone to have diets higher in carbohydrates, lead a very sedentary lifestyle, and eat more often at fast-food restaurants. Obesity puts a person at risk for the disease; other risk factors include high cholesterol levels, high blood pressure, a family history of diabetes, gestational diabetes during pregnancy, and having given birth to a baby weighing more than nine pounds.
“People over the age of 45 should begin to be screened once every three years for diabetes by having their glucose levels checked.”
Based on CDC research, more than 40 percent of Kentuckians age 40-74 have prediabetes and are at very high risk for developing the disease. Prediabetes is defined as an elevated blood sugar level that isn’t quite high enough to be diagnosed as diabetes.
More than 80 percent of type 2 diabetes cases can be prevented. Just getting blood glucose levels below 7 percent greatly reduces a person’s risk. People over the age of 45 should begin to be screened once every three years for diabetes by having their glucose levels checked.
Those who develop diabetes can most effectively control the disease and reduce the risk of complications by eating healthfully; participating in regular physical activity; monitoring their blood glucose levels daily; taking medications or injecting insulin as needed; keeping problem-solving skills sharp; quitting smoking; and getting regular eye, foot and dental examinations.
Dr. Johnson is an assistant professor in Pharmacy Practice and Science at the UK College of Pharmacy. She is also a certified diabetes educator.
Each issue of Advances & Insights summarizes an important piece of medical news, accompanied by commentary from a UK expert.
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