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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
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
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
• 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
“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
“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
program of diabetes self-management.
It is a pharmacist-provided
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
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
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
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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