Type 2 Diabetes and Obesity in Southern US

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1 Geography Matters: Age-adjusted Percentage of U.S. Adults with Obesity or Diagnosed Diabetes Type 2 Diabetes and Obesity in Southern US The Scope of the Problem Obesity & Diabetes in Adults Obesity Diabetes Diabetes Belt United States Prevalence of Population With Diagnosed Diabetes Diabetes Belt = 11.7% Rest of U.S. = 8.5% Data from Behavioral Risk Factor Surveillance System (BRFSS) for 2007 and Features of the Diabetes Belt versus Rest of United States 40% 30% 20% 10% Diabetes Belt Rest of US Prevalence of Obesity Among Those With Type 2 Diabetes T2DM Patients (%) NHANES (N=1444) 13% Normal (BMI <25) 24% 63% Overweight (BMI 25-29) 0% African Americans With Diabetes Obesity Sedentary Lifestyle 20 0 Obese (BMI 30) Barker LE, et al. Am J Prev Med. 2011;40(4): BMI, body mass index, in kg/m 2. Ali MK, et al. New Engl J Med. 2013;368:

2 Adult Obesity Facts: West Virginia Childhood Obesity Facts: West Virginia Current adult obesity rate (2015) 35.6% Obesity rate by age (2015) % 2- to 4-year-olds from low-income families 10- to 17-year-olds High school students 2/ % 43.2% 36.8% Current obesity rate (2011) 14% Rank among states (2011) Current obesity rate (2011) 18.5% Rank among states (2011) Current obesity rate (2015) 17.9% Obesity rate by race (2015) 21/41 13/51 5/43 Latino 40.2% Black 41.5% White 35.2% Diabetes and Hypertension: West Virginia Current adult diabetes rate (2015) 14.5% 2/51 Diabetes Current adult hypertension rate (2015) 42.7% 1/51 Hypertension Overweight and Obesity Increase the Risk of Cardiovascular Disease Mortality Relative Risk 2.2 of Cardiovascular Disease 1.8 Mortality 1.4 Men Women Normal weight Overweight Obese > >40 BMI, kg/m 2 Data are from 1 million men and women (average age, 57 years) followed for 16 years who never smoked and had no history of disease at enrollment. Calle EE, et al. N Engl J Med. 1999;341: Microvascular Complications: Key Statistics In , of adults 40 years of age with diabetes, 4.2 million (28.5%) had diabetic retinopathy. 655,000 (4.4%) had advanced diabetic retinopathy In 2010, about 73,000 non-traumatic lower-limb amputations were performed in adults 20 years of age with diabetes. About 60% of non-traumatic lower-limb amputations among adults 20 years of age are in people with diabetes. Diabetes was listed as the primary cause of kidney failure in 44% of all new cases in Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, Atlanta, GA: U.S. Department of Health and Human Services; Evidence for Benefit of Glycemic Control in Type 2 Diabetes According to the United Kingdom Prospective Diabetes Study (UKPDS) 35,* Every 1% in HbA1c Resulted in: 21% 14% 12% 37% in risk of any diabetes-related endpoint (P < ) in risk of myocardial infarction (P < ) in risk of stroke (P = 0.04) in risk of microvascular complications (P < ) *The study population was 82% White, 10% Asian Indian, and 8% Afro-Caribbean. Stratton IM, et al. BMJ. 2000;321:

3 Steno-2 Study: Reduction in CVD and Microvascular Disease Adults Who Should Be Screened for Diabetes and Prediabetes Reductions After 7.8 Years of Intensive vs Conventional Rx Percentage Gaede P et al. N Engl J Med. 2003;348(5): CVD Nephropathy Retinopathy Autonomic Dysfunction Symptoms consistent with diabetes Anyone over age 45 Overweight (BMI 25) and 1 additional risk factor If normal results, repeat testing at least every 3 years IGT: impaired glucose tolerance IFG: impaired fasting glucose. ADA. Diabetes Care 2016;39(Suppl. 1):S1 S112 Additional Risk Factors Physical inactivity First degree relative with diabetes Member of high-risk ethnic population Hypertension ( 140/90 mm Hg or on HTN therapy) HDL-C <35 mg/dl and/or triglyceride >250 mg/dl Prediabetes (HbA1c 5.7%, IGT or IFG on previous testing) History of cardiovascular disease Culturally Sensitive Approaches for Breaking Down Barriers to Weight and Glycemic Control Patient Centered Care Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions Institute of Medicine Committee on Quality of Health Care in America Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, The National Academies Press, Dietary Challenges to Weight Reduction: Lack of Access to Healthy Food Dietary Challenges to Weight Reduction: African Americans Soul Food High in starch (e.g., biscuits, sweet potatoes, beans) and sodium High fat: meats with high fat content e.g., fried chicken and fatty cuts of meat like pork often prepared with lard or other saturated fat product Fat intake may comprise close to 50% of calories Mean daily intake of fruits and vegetables may be very low (0.88 and 1.64 servings per day) Kim KH, et al. Health Educ Behav. 2008;35: Satia JA, et al. Public Health Nutr. 2004;7:

4 Dietary Challenges to Weight Reduction: Hispanics Overall shift is toward less healthy diets. With US acculturation, Mexican- Americans eat more saturated fat, salt, desserts, pizza, and french fries than counterparts in Mexico. In the overall Hispanic population, acculturation is associated with poorer diet, higher alcohol consumption, and higher rates of obesity. Interventions such as DIALBEST, which take acculturation factors into account, can improve diabetes self-management among Latinos. Batis et al. J Nutr. 2011;10: Perez-Escamilla Am J Clin Nut 2011;93(suppl):1163S-1167S. Potential Barriers to Adequate Diabetes Care in Diverse Populations Can Include: Inadequate education Language/literacy barriers Lack of/inadequate insurance Potential for suboptimal patientphysician relationship Limited culturally relevant educational programs Cultural beliefs Lack of transportation Lack of child care arrangements Glazier et al. Diabetes Care. 2006;29: Sarkar et al. Diabetes Care. 2006;29: Saha et al. Am J Pub H. 2003;93: Cultural Insights: Hispanics and Diabetes Accept that diabetes has biomedical causes such as heredity. Traditional or folk beliefs such as sustoconcept of strong emotions. Strong religious beliefs May adopt fatalistic approach to diabetes management: It s in God s hands. Belief in value of herbal medicines. Negative cultural attitudes toward insulin. Patients may fear being scolded by clinician. Hatcher E, et al. J Am Acad Nurse Pract. 2007;19(10): Caballero A E, et al. J Fam Pract. 2007;56(9):S29-S38. Hispanic Culture: Communication Implications Use Senor and Senora or proper names during interview, rather than first name. Avoid firm hand shakes, which imply that the doctor is overpowering. The patient s indirect eye contact is a show of respect for the physician. Physician shows respect by sitting or standing near patient. Hatcher E, et al. J Am Acad Nurse Pract. 2007;19(10): Caballero A E, et al. J Fam Pract. 2007;56(9):S29-S38. Cultural Insights: African Americans and Diabetes Spirituality is an important factor in general health, disease adjustment, and coping Belief in prayer, trusting in God Use of bitter foods and herbs (lemon juice, vinegar, garlic, juniper berries) to treat diabetes (more common in rural areas) Belief that sugar or sweet blood is caused by imbalance in eating (too much sugar and starchy foods) A diagnosis of sugar is less serious than one of diabetes Belief that legacy of slavery and segregation may play a role in onset of diabetes Successful Strategies to Improve Diabetes Outcomes in African Americans and Hispanics Use social networks (family members, peer support groups, churches, one-on-one interactive education, community health workers) Use culturally tailored interventions and education Language, diet, social emphasis, family participation, cultural beliefs Emphasize cognitive behavioral education, self-care management, and adaptations of the Diabetes Prevention Program (DPP) Focus on improving patient resilience to stressors Tripp-Reimer T. Diabetes Spectr. 2001;14: Jones et al. Altern Ther Health Med. 2006;12: Wagner JA, et al. J Natl Med Assoc. 2011;103: Baig AA, et al. Med Care Res Rev. 2010;67(5 Suppl):163S-197S. Brown et al. Diabetes Care. 2002;25:

5 Successful Strategies to Improve Diabetes Outcomes in African Americans and Hispanics (cont d) Use of care management, community health workers (CHWs), and non-physician professionals: CHW (can be RNs) serve as a patient adjunct to the primary care team Assists care management Helps overcome social, cultural, linguistic barriers Acts as a powerful change agent Pharmacist-led medication management Use of medical (or medication) assistance programs (MAPs) Baig AA, et al. Med Care Res Rev. 2010;67(5 Suppl):163S-197S. Successful Strategies to Improve Diabetes Outcomes in African Americans and Hispanics Educational Programs Bilingual educators facilitate the class Provide food models common to Mexican- American diets Education materials in Spanish de Peralta E, et al. Tex Med. 2005;101(6): Clancy DE, et al. Top Health Inf Manage. 2003;24(1):8-14. Clancy DE, et al. Diabetes Educ. 2007;33(2): Group Visits for Underinsured Small groups of patients meet with health care professionals for 2 hours of education + one-on-one consultations Sense of trust in physician Coordination of care Cultural competency of care Does it Work? Engage Community Churches Community-based African American churches successfully implemented diabetes prevention programs (DPP) and diabetes self-management programs Lowered fasting glucose and weight in at-risk participants Lowered HbA1c and weight, and raised diabetesrelated quality of life in participants with T2DM Boltri JM, et al. J Natl Med Assoc. 2011;103(3): Samuel-Hodge CD, et al. Diabetes Educ. 2009;35(3): Tips for Culturally Competent Care Broadly: Value patients cultural beliefs and avoid stereotyping Involve the community and address service needs Collaborate with other agencies Institutionalize cultural competency Specifically: Ask your patients about their health beliefs Discuss traditional healing remedies Discuss the role of advice from family members and friends in making healthcare decisions Offer to include family members in health discussions Thom DH. BMC Med Educ. 2006;6:38. National Diabetes Education Program. Explanatory Model for Culturally Competent Care Examples of questions you can ask your patients: What do you think caused this problem? What have you done to treat this? Have you asked anyone for help? How might your parents have treated this? What do you want the medicine to do? How does your faith help you to be well? Are there any foods or drinks that you think can help you with (condition)? Strengthening Clinician-Patient Interactions: Motivational Interviewing Core principles of motivational interviewing: Development of discrepancy: explore the gap between current practices and broader health goals. Embracing ambivalence: explore patients ambivalence about change. Support for self-efficacy: Help patients believe they can change their behavior to achieve better outcomes. Expression of empathy: Understand patients feelings without judging or blaming. Roll with resistance: Use patient resistance as a signal that a change in communication tactics is needed. National Diabetes Education Program. Fisher et al. Clinical Diabetes. 2013;31:

6 The Five A s of Healthcare Interactions Sequential series of steps to use during healthcare interactions, which facilitate patient-centered care and patient self-management Assess Advise Agree Assist Arrange Emphasizes: Collaborative goal setting Patient skill building to overcome barriers Self-monitoring Personalized feedback Systematic links to community resources Meriwhether RA. Am Fam Physician Apr 15;77(8):

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